18Chapter

SuicideLisa Seyfried, MD, and Joel J. Heidelbaugh, MD

Key Points

� The US Preventive Services Task Forceconcluded that evidence is insufficient torecommend for or against routine screeningfor suicide during office visits (strength ofrecommendation: C).

� Contracts for safety in patients who may beat an increased risk for suicide have not beenproved to be effective in reducing attemptsor deaths from suicide (strength ofrecommendation: C).

� Although a black box warning has beenissued concerning increased suicidal ideationand behavior associated with antidepressant(specifically SSRI) drug treatment in childrenand adolescents, this is not an absolutecontraindication. Consultation with apediatric mental health professional shouldbe considered when treating children andadolescents with major depressive disorderwho may be at an increased risk of suicide(strength of recommendation: C).

Introduction

According to the National Center for Health Sta-tistics, suicide was the eleventh leading cause ofmortality in the United States in 2003, accountingfor 31,484 deaths or 1.3% of total US deaths.1 Menwere 4.3 times more likely to die by suicide; theratio of completed suicide in both of AfricanAmerican and Hispanic men as related to non-Hispanic white men was 0.4 in 2003.1 Suicidologyliterature consistently demonstrates that, world-wide, men of all ages are at a higher risk for sui-cide than women, with only few exceptions.2,3

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The act of suicide is the result of a complexinteraction between risk and protective factors.Population studies have identified several factorsassociated with suicide completion in men; yet,at an individual level, these data do little to helpthe clinician determine which patients will even-tually commit suicide. Given the low baseline rateof suicide in the population, even in populationsat high risk, it is almost statistically impossible toreliably predict suicidality at the level of the indi-vidual. In a 2006 review, Paris4 concluded that“given our present knowledge. . . it is not possibleto predict suicide with any degree of accuracy.”

Despite a lack of evidence-based guidelinesfor suicide risk assessment, clinicians must carryon in their attempts to predict and prevent sui-cide in their patients. Given that one half to twothirds of persons who complete suicide have vis-ited a primary care professional within 1 monthof their death,5 we are commonly placed ina unique position to appropriately detect andintervene. The assessment of suicide and suicidalbehavior is relevant to all clinicians and is notlimited solely to mental health professionals.

The Gender Paradox

Although men tend to complete suicide moreoften than women, women attempt suicide farmore often than men. This trend is often referredto as the “gender paradox” of suicidal behavior.6

Several explanations for this paradox have beenproposed. One of the most frequently positedreasons relates to gender difference in choice ofsuicide method. Men who commit suicide tendto choose more violent and immediately lethalmeans, such as firearms, at a higher rate than

Table 18-1. Criteria for Major Depressive Disorder*

� Depressed mood most of the day, nearly every day, as

indicated by either subjective report (e.g., feels sad or

empty) or observation made by others (e.g., appears

tearful) (In children and adolescents, this may be

characterized as an “irritable” mood.)

� Markedly diminished interest or pleasure in all, or

almost all, activities most of the day, nearly every day

� Significant weight loss when not dieting or weight

gain (e.g., a change of more than 5% of body weight

in a month) or decrease or increase in appetite nearly

every day

� Insomnia or hypersomnia nearly every day

� Psychomotor agitation or retardation nearly every day

� Fatigue or loss of energy nearly every day

� Feelings of worthlessness or excessive or inappropriate

guilt nearly every day

� Diminished ability to think or concentrate, or

indecisiveness, nearly every day

� Recurrent thoughts of death (not just fear of dying),

recurrent suicidal ideation without a specific plan, or a

suicide attempt or a specific plan for committing

suicide

*Apersonwith amajor depressive disordermust either have a depres-

sed mood or a loss of interest or pleasure in daily activities

consistently for at least a 2-week period. This mood must represent

a change from the person’s normal mood; social, occupational,

educational, or other important functioning must also be

negatively impaired by the change in mood. A depressed mood

caused by substances (e.g., drugs, alcohol, medications) is not

considered a major depressive disorder, nor is one that is caused by

a general medical condition. Major depressive disorder cannot be

diagnosed if a person has a history of manic, hypomanic, or mixed

episodes (e.g., bipolar disorder) or if the depressed mood is better

accounted for by schizoaffective disorder and is not superimposed

on schizophrenia, a delusion, or psychotic disorder.

Furthermore, to qualify as a major depressive disorder, the

symptoms are not better accounted for by bereavement (i.e., after

the loss of a loved one), the symptoms persist for longer than

2 months or are characterized by marked functional impairment,

morbid preoccupation with worthlessness, suicidal ideation,

psychotic symptoms, or psychomotor retardation.

Reprinted with permission from The Diagnostic and Statistical

Manual of Mental Disorders,Fourth Edition, Text Revision (Copyright

18Suicide

women.7 Although a considerable number ofwomen do use firearms, they are more likely tochoose less lethal means including drug overdoseand carbon monoxide poisoning.8 One interpreta-tion of these data is that these findings reflect adifference in level of intent; some studies9 reportthat men have higher level of intent than womento actually succeed in killing themselves, whereasothers6,8 have not supported that conclusion.

Another theory related to this paradox sug-gests that gendered beliefs and attitudes aboutsuicide contribute to differences in suicidal behav-ior. It has been suggested that, in the UnitedStates, attempting suicide tends to be thought ofas a somewhat “feminine” behavior in contrastto committing suicide, which is perceived as a“masculine” behavior.10 In research on the roleof gender in attitudes toward suicidal behavior,men appear to be more accepting of suicide andtend to view it as a matter of individual right.11

Early work by Linehan12 discovered that maleswho survived a suicide attempt were viewed asless masculine and potent by their peers thanthose who succeeded in killing themselves. Menmay be viewed as acting “powerfully” whencommitting suicide in response to a debilitatingillness or a serious achievement failure10; therehave been examples of this trend that havereceived national media attention in recent years.In lieu of attempting suicide, males are statisti-cally more likely to engage in more “sociallyacceptable” self-destructive and high-risk behav-ior including alcohol and illicit drug abuse. In acomprehensive review of this issue, Canetto andSakinofsky6 concluded that “an important influ-ence on the gender paradox may be culturalexpectations about gender and suicidal behavior.”

2000). American Psychiatric Association.

Gender, Depression, andSuicide

Depression is one of the most commonly citedrisk factors for suicide. Large-scale epidemiologicstudies have repeatedly demonstrated a signifi-cant gender difference in rates of major depres-sive disorder, with prevalence of depressiontwice as high in women than in men13,14; criteriafor major depressive disorder are listed inTable 18-1. Still, despite lower identified rates ofdepression in males, men are successful at com-mitting suicide far more often than women.

Gender differences in depression have beenwell investigated in the literature. One of themost consistent findings is the 2:1 (female tomale) gender ratio in the prevalence of major

depression.15 This difference in prevalence beginsaround puberty and persists through the fifthdecade of life. Numerous explanations have beenposited to explain this difference in prevalence,although none have been sufficiently supportedby clinical evidence. Some researchers have pro-posed that gender differences in the course ofdepression might explain the lower prevalenceamong males. Although several studies havereported a similar course for men and women,the majority have identified lower relapse andnonremission rates among men.16 Differences inhelp-seeking behavior may artificially increasethe difference in prevalence (see Chapter 4, Menand the Problem of Help Seeking). Men oftenhave longer delays and lower rates of treatmentcontact than women.17,18 Some research suggests

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Table 18-2. Risk Factors for Suicide

Demographic features Male gender

Widowed or divorced

Age 60 years or older

White race

Psychosocial features Living alone

Unemployed or with

financial problems

Recent stressful life event

Psychiatric diagnoses Major depressive disorder

(see Table 18-1)

Alcohol/substance abuse

Cluster B personality

disorders

Psychological features Feeling of hopelessness

Severe or unremitting

anxiety

Panic attacks

Genetic and familial effects Family history of suicide

(particularly in first-

degree relatives)

Family history of mental

illness, including

substance use disorders

3Special Concerns of the Adolescent and Adult Male

that men are less reliable historians when itcomes to affective states and have difficultyrecalling the frequency and duration of theirdepressive episodes19; however, there is also sub-stantial evidence against this theory.16,20 Anothercontroversial explanation for the difference inprevalence suggests that men are less likely thanwomen to experience an episode of major depres-sion in response to stressful life events.21

Limited research has addressed gender-related variations in the symptoms of depression,and a significant proportion is conflicting. Forexample, a large community-based study ofdepressed outpatients found no gender differ-ences in the severity or symptomatology ofdepression,22 yet numerous additional studieshave noted some differences. Several researchershave attempted to distinguish a separate “maledepressive syndrome,” proposing that there isan inherent gender-related bias in our currentcriteria.23 Rutzt and Walinder24 describe a malesubtype of depression characterized in part bytemporary lower stress tolerance, acting out,aggression, low impulse control, indecisiveness,irritability, substance abuse, and anti-socialfeatures. Other studies also report that depressedmen, compared with women, tend to experiencelower impulse control, increased irritability, andanger.25 In addition, men appear more likelyto complain of insomnia and agitation.26 Manystudies suggest that men are less likely to havea significant change in appetite, hypersomnia,fatigue, and psychomotor retardation.27,28 Inboth sexes, major depression has been shown tolead to limitations and impairments in dailyactivities, yet men appear more likely to reportimpairments in work and leisure activities.29,30

Physicians are less likely to recognize depres-sion and suicidality in male patients than infemales. It appears that gender-related stereo-types on the part of clinicians play a role in theunderdiagnosis of major depression in men.31 Inturn, men are much less likely to acknowledgeand discuss physical and psychological distresswhen meeting with their physicians and find itmore difficult to divulge personal informationthat may be at the root of such mood changes.32

This dangerous combination presents a signifi-cant challenge to the identification of men withdepression and suicidal ideation.

Additional features History of suicide

attempts or ideation

Access to firearms

Identifying Men at Risk

Adapted from: American Psychiatric Association: Practice Guidelines

for the Assessment and Treatment of Patients with Suicidal

Behaviors, Washington, DC, 2003, American Psychiatric Association.

No one can predict with certainty whether anindividual will or will not attempt suicide. Atpresent, there are no risk-assessment techniques,

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no diagnostic criteria, and no screening toolsavailable that can accurately predict suicidalbehavior in any given patient. The US PreventiveServices Task Force33 2004 review of studies onroutine screening by primary care clinicians todetect suicide risk in the general population con-cluded that the evidence is insufficient to recom-mend for or against this practice. The goal ofa suicide assessment is therefore not to predictsuicidal behavior but rather to identify those peo-ple who may be at a greater risk and to evaluateindividual factors that may influence acute riskso as to inform clinical practice.34,35

Table 18-2 lists several factors that have beenassociated with an increased suicide risk. As thetable demonstrates, male-to-female predomi-nance in suicide in the United States continuesacross the life span, and the largest gender differ-ence in suicide rates occurs among older agegroups. For example, men who are 65–74 yearsold are nearly six times more likely to commitsuicide than age-matched females. It is alsoimportant to remember that suicide is the thirdleading cause of death in young men betweenthe ages of 15 and 24 years.

18Suicide

Race may also be an important considerationbecause the risk of completing suicide is morethan double for the white population comparedwith the African American population.1 Whitemales over the age of 85 years have the highestsuicide rates compared with all age and gen-der groups. Data from the National Surveyof American Life36 sampled 5181 blacks aged18 years and older who were categorized asAfrican Americans and Caribbean Americans.The reported lifetime prevalence for suicidalideation in this study group was 11.7% and forsuicide attempts was 4.1%. Among the respon-dents who reported suicidal ideation, 34.6% actu-ally transitioned to making a plan and only 21%made an unplanned attempt. This study deter-mined that blacks at a higher risk for suicideattempts were in younger birth cohorts, lesseducated, and residents of the MidwesternUnited States and had one or more psychologicaldisorders classified by the Diagnostic and Statisti-cal Manual of Mental Disorders, Fourth Edition.

Past psychiatric history is one of the strongestpredictors of suicide because approximately 90%of persons who commit suicide have a diagnos-able mental illness.37 As discussed previously, itis estimated that 50% of men who commit suicidehave major depressive disorder.38 In a meta-analysis of 249 studies, Harris and Barraclough39

estimated the suicide risk associated with com-mon psychiatric disorders. They demonstratedthat the rate of suicide exceeded the expected ratein the general population by 20 times in majordepression, 10 times in panic disorder, 7 timesin personality disorder, and nearly 6 times inalcohol abuse. A history of past suicide attemptswas found to be correlated with a suicide risk 38times greater than that of the expected population.These results are consistent with those fromnumerous other studies; however, the vast major-ity of patients with psychiatric illness do not com-mit suicide. The challenge herein is to recognizewhat psychological characteristics place somepatients at a higher risk than others for attemptingand completing suicide. Mann and colleagues40

found that the severity of subjective feelings ofdepression and suicidal ideation were bothindicators of an elevated risk for future suicidalacts. This ideal is consistent with earlier worksuggesting that the more severe the depression,the higher the acute risk of a suicide attempt.41

Alcohol abuse and dependence is an impor-tant risk factor for suicide and, like suicide, isa gendered phenomena.42 Alcohol use disordersoccur more frequently in men compared withwomen. In the National Comorbidity Survey in

the United States, the 12-month prevalence ofalcohol dependence in males was 20.1%—approximately 2.5 times the rate in females.13 Ina review of the literature, Murphy and Wetzel43

found that the lifetime risk of suicide in patientswith alcoholism was between 60 and 120 timesthat of the non–psychiatrically ill. They estimatethat 25% of persons who commit suicide havean alcohol use disorder. Several studies havedemonstrated that acute alcohol use is also asso-ciated with suicidal behavior.44 It is possible thatthis notion is a direct result of alcohol’s physio-logic effects, which include increasing aggressive-ness and decreasing inhibition. Some studieshave suggested that ingestion of alcohol mightpredispose persons to the choice of guns forcommitting suicide, but current data areconflicting.45,46

A growing body of evidence exists that sug-gests that impulsive and aggressive behaviors indepressed men may play a significant role in sui-cide.40 In a 2005 study of male suicide comple-ters, impulsive-aggressive personality disordersand alcohol abuse or dependence were found tobe two independent predictors of suicide in casesof major depressive disorder.47 This finding wasconsistent with numerous other studies that haveidentified borderline and antisocial personalitydisorders as risk factors for suicidal behavior.The “cluster B” personality disorders (commonlyreferred to as the dramatic and erratic personalities),particularly the borderline and antisocial person-ality disorders, are highly correlated with impul-sivity and aggression. In this study, 70% ofcompleted suicides in patients with a knowncluster B personality disorder had concomitantproblems with alcohol and/or drug abuse ordependence.47

Numerous medical illnesses have been asso-ciated with increased risk of suicide, some inde-pendent of the effects of comorbid psychiatricdisorders. Pulmonary disease (particularly chro-nic obstructive pulmonary disease), congestiveheart failure, urinary incontinence, peptic ulcerdisease, cancer, migraine with aura, epilepsy,stroke, multiple sclerosis, traumatic brain injury,Huntington’s disease, and acquired immunodefi-ciency syndrome all carry a higher risk for sui-cide.48–51 In addition, the risk is greatlyincreased among patients with multiple chronicillnesses.48

A final risk factor to consider in suicidality isthe experience of hopelessness. A high degree ofhopelessness is more significantly related tosuicidal behavior than depressed mood alone.40

A 1990 study of 1958 psychiatric outpatients

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3Special Concerns of the Adolescent and Adult Male

found that those with greater levels of hopeless-ness were 11 times more likely to commit suicidethan the rest of the outpatients.52 Depressedpatients who are “future oriented,” defined asthose who look to the future with a generallypositive outlook and who can identify goals andreasons for living, have fewer and less intensethoughts of attempting suicide.53

Protective factors, specifically those associatedwith a reduced risk for suicide, must also be con-sidered. Married men experience lower suiciderates than those who are divorced or sepa-rated.54,55 Having children, particularly youngerchildren in the home, is also associated with areduced suicide risk.56 Overall, persons who havea strong religious faith and believe that suicide ismorally wrong or sinful also appear to havedecreased risk.57,58 Social connectedness, prob-lem-solving confidence, and an internal locus ofcontrol are thought to be protective against sui-cide attempts in young adults.59

Acute Risk Factors: WarningSigns for Suicide

An emerging area of suicidology research con-cerns itself with the warning signs for suicide.As Rudd and colleagues60 have noted, comparedwith the aforementioned risk factors, warningsigns “suggest a more proximal rather than distalrelationship to suicidal behaviors.” They implymore imminent risk (i.e., days to weeks) thando risk factors, which suggest long-term risk(i.e., months to years). Using a consensus process,the American Association of Suicidology hasdeveloped a list of suicide warning signs for useby clinicians and the lay public. This list issummarized by the mnemonic “IS PATHWARM?”60,61:

� I: Ideation (suicidal ideation)� S: Substance abuse (increasing alcohol orillicit drug use)

� P: Purposelessness (no reason to live, nosense of purpose in life)

� A: Anxiety� T: Trapped (feeling like there is no way out)� H: Hopelessness� W: Withdrawal (withdrawing from friends,family, or society)

� A: Anger (rage, revenge seeking)� R: Recklessness (engaging in risky behaviors)� M: Mood changesThese various signs reflect the current state of

the patient and may be useful to the clinician inthe assessment of impending suicide risk. When

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inquiring about suicidal risk, documentation ofany or all of the above signs is paramount, aswell as ensuring the immediacy of patient safety.

The Psychiatric Interview

A thorough psychiatric examination is the foun-dation of any suicide assessment. The psychiatricinterview and mental status examination areessential elements in determining risk and pro-tective factors for suicide. In addition, the inter-view can help to establish a rapport between thepatient and clinician. Of note, interviewer gendermay influence disclosure in mental health inter-views. Some research suggests that men inter-viewed by a woman are likely to report slightlymore symptoms of depression than those inter-viewed by a man.62 Collateral information shouldalso be obtained from family members, otherphysicians, and the medical record when allowedby the patient. Important elements of the psychi-atric interview include the following63:� The patient’s psychiatric history: Obtaining thepatient’s personal psychiatric history is critical.This can often be approached during thereview of systems or while obtaining the medi-cal history. It is also important to ask specificand directed questions about any past suicidalbehavior. Prior suicide attempts are among thestrongest risk factors for completed suicideand may be the best single predictor of com-pleted suicide.64

� Family history: The family psychiatric historymay provide important clues to understandingthe patient’s current mental state. It is ofteneasiest to obtain this information whilegathering the family medical history. Topics ofparticular importance include mood disordersand substance abuse or dependence, as thesemay indicate a genetic vulnerability in thepatient. Men have a 60% increased risk for alco-hol abuse and dependence if they report thattheir father has a history of heavy drinking.65

Numerous studies have determined that a fam-ily history of suicide is associated with anincreased risk of suicidal behavior.66, 67

� Social history: This is an opportunity for the cli-nician to not only gather data but also to assessthe patient’s overall social situation. Questionsabout work, home life, religion, and legal issuesshould be posed. Men appear to be particularlyvulnerable to depression during times of mari-tal discord and economic hardship.68

� Mental status examination: The mental statusexamination is a systematic assessment of

18Suicide

the patient’s current mental state. The mostpertinent elements include the following:

� Appearance: Patients who are very depres-sed often have difficulty attending to activ-ities of daily living, including grooming.The level of psychomotor activity shouldbe noted; in depressed patients, this canrange anywhere from slowed to agitated.

� Mood and affect: The assessment of apatient’s mood has two salient compo-nents, namely what the patient reports ashis mood and what the clinician observes;these determinations can occasionally beincongruous. The term affect refers to theobservable expression of emotion suchthat a man who appears sad and tearfulmay report that his mood is “fine.”

� Hallucinations and delusions: Somepatients will develop psychotic symptomsas part of their depression. This is impor-tant to assess because psychosis is anindependent risk factor for suicide.

� Suicidal ideation: The specifics of suicideassessment are covered below.

Assessment of SuicidalIdeation

Forming an accurate assessment of suicidal idea-tion in men is particularly challenging. As notedearlier in this chapter, most men have a difficulttime discussing their true feelings. In addition,the stigma surrounding mental illness and sui-cide often deters them from seeking treatmentin the first place.69 Very few men will spontane-ously disclose suicidal ideations to their physi-cian.70,71 In turn, physicians are sometimesuncomfortable discussing these issues with theirpatients because suicide assessment in particularmay provoke anxiety in some clinicians; physi-cians may hesitate to ask their patients about sui-cide in the belief that this could trigger suicidalthoughts and behavior despite the lack of anyempiric evidence supporting this fear. Still othersmay believe that the patient will spontaneouslycommunicate suicidal intent himself.72 Given thatsuicidal patients are far more likely to anticipatedifficulty in talking to their physicians aboutpsychiatric problems than those who are notsuicidal,73 the responsibility to explore theseissues falls on the primary care clinician.

A hierarchical stepwise approach to question-ing has been recommended by several expert sui-cidologists.74,75 This method is consistent with

the American Psychiatric Association’s PracticeGuidelines for the Assessment and Treatment ofPatients with Suicidal Behaviors.34 In this type ofinterview, the clinician typically begins withgeneral and open-ended questions (e.g., “Howare things going in your life?”) in an attempt toidentify any current stressors. Then, the intensityand degree of detail in questioning is slowlyincreased. Questions such as “Have you ever feltthat life was not worth living?” and “Did youever wish you could go to sleep and just notwake up?” help to broach the subject of death.In addition, it can be helpful for the clinician tonormalize these thoughts (e.g., “Sometimes peo-ple who are depressed/divorcing/just lost theirjob/etc. have thoughts that it would be better tonot go on. Have you had any thoughts likethat?”). It is important to then follow up withspecific directed questions about thoughts ofself-harm or suicide. Questions like “Is deathsomething you’ve thought about recently?” and“Have things ever reached the point that you’vethought about harming yourself?” can be helpfulin eliciting such thoughts.

By approaching a suicide assessment in thismanner, the clinician should be able to establisha better rapport with the patient, thereby allow-ing him to feel more comfortable about sharingdifficult and potentially disturbing thoughts overtime and through subsequent encounters. If thepatient admits to having thoughts of death or sui-cide, then the clinician should continue his or herline of questioning by inquiring about detailedaspects of the suicidal thoughts. The patientshould be asked about specific plans for suicideand any steps that have been taken toward enact-ing those plans. To assess type of method, onemight simply ask, “What have you been thinkingof doing?” and follow up with “Have you consid-ered any other methods?” A highly organizedand detailed plan is generally associated with agreater risk, although suicide attempts can occurimpulsively with little or no planning.34 A planinvolving a violent, lethal, and easily accessiblemethod is particularly concerning because itimplies a high level of intent; the notion of intentrefers to the degree of seriousness of the patient’swish to die. When assessing intent, it is importantto ascertain the patient’s beliefs and knowledgeabout the suicide method. For example, he maybelieve that acetaminophen is relatively safe inan overdose since it is available over the counter.Thus, he may have a low intent but may havea plan that is highly lethal. The converse ofthis relationship is true as well, as some people

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3Special Concerns of the Adolescent and Adult Male

will devise a plan that they erroneously believewill be lethal in a sincere wish to die. Thesepeople should be considered at a higher risk forsuicide based on their level of intent.

Management

Once it has been determined that a patient is sui-cidal, the clinician must devise a comprehensivetreatment plan that addresses patient safetybased on level of risk for suicidal behavior.76

Immediate action must be taken when a man isjudged to be at imminent risk. Rapid evaluationby a mental health professional is warranted withinpatient psychiatric hospitalization a likely andpractical outcome. Often, this will involve trans-ferring the patient by ambulance to a nearby hos-pital and direct communication of medicalinformation and concerns between the clinicianand mental health professional who will be eval-uating and treating the suicidal patient. Regard-less of the patient’s level of cooperation, one-to-one constant staff observation is indicated whilethese arrangements are being made. The situationbecomes more difficult if the patient rejects thephysician’s recommendations. In these cases, theclinician must explore medical-legal avenueswith appropriate risk-management experts,which typically involve calling local authoritiesfor assistance. Although this can be anxietyprovoking for the physician and can strain thedoctor-patient relationship, ultimately patientsafety must be the first priority.

If the patient is believed to be at a moderatebut not imminent risk for suicide, he often canbe managed in the outpatient setting. If allowedby the patient, family or others close to himshould be actively involved in the treatment plan.The patient should be made aware of the avail-ability of any available 24-hour emergency or cri-sis intervention services. It is often helpful toincrease the frequency and duration of outpatientvisits in these cases, during which frequentreevaluation of suicide risk should be performedand documented in detail. Depending on theclinician’s level of comfort with psychiatric pro-blems, a referral to a mental health specialistmay be indicated. Patients with suicidal beha-viors frequently benefit from treatment involvinga multidisciplinary team that may include severalmental health professionals.

The use of suicide prevention contracts as apart of a clinical treatment plan is controversialat best. Contracts are often used in an attemptto ensure that a patient will inform someone ifhe feels unable to resist his suicidal thoughts.

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No studies to date have demonstrated their effec-tiveness in reducing suicide. In fact, studies ofcompeted suicides have shown that a significantnumber had such a contract in place at the timeof their suicidal act34; however, some cliniciansfind them to be a useful tool in assessing riskand strengthening the therapeutic alliance.

Lastly, the management of any patient at riskfor suicide, particularly high-risk men, mustinclude a conversation about firearms. The pres-ence of one or more guns in the home is asso-ciated with a four-fold increased risk of suicide.7

Men with firearms in the home are 10 times morelikely to commit suicide than men without gunsin the home.77 The clinician who is interviewinga depressed or potentially suicidal patient shouldrecommend that the patient remove any firearmsfrom his house. This practice can prove to bea difficult negotiation with some patients. Clini-cians should also attempt to educate the patientand his family about the aforementioned risksand suggest that all firearms be made inaccessibleto the patient. Patients, in an attempt to be reas-suring, may state that they keep their gunsunloaded and in a locked location. There is a largebody of research that demonstrates a strong asso-ciation between guns and risk of suicide existsregardless of storage practice, type of gun, ornumber of firearms in the home.77 The removalof all firearms from the home is the safest option.

Suicide and the Potential Linkto Pharmacotherapy

The controversy regarding the relationshipbetween selective serotonin reuptake inhibitors(SSRIs) and suicidality dates back to the early1990s. Although the first agent reported to beassociated with suicidality was fluoxetine, in2003 the British Medicines and HealthcareProducts Regulatory Agency warned abouta possible risk of suicidality in children and ado-lescents treated with paroxetine for major depres-sive disorder. This warning was soon extended tothe SSRIs as an entire class as well as venlafaxineand mirtazapine.78 In 2004, the US Food and DrugAdministration issued a “black box warning”concerning increased suicidal ideation and behav-ior associated with antidepressant (specificallySSRI) drug treatment in children and adolescents.Despite numerous studies and reviews examiningthis topic, it is still largely unknown whetherantidepressant agents, specifically the SSRIs,actually increase the risk of suicide death in chil-dren or adults, as current data are conflicting.79

18Suicide

Bostwick80 comments that “after regulatoryagencies in the United Kingdom and the USrecommended severe restrictions on antidepres-sant use in children, many lessons were learned,although one was not that these drugs cause sui-cide. There has been enormous speculation thatpharmaceutical companies selectively releaseddata that reflected positively on their productsand that combining suppressed and publisheddata suggested that most of these medicationshad questionable efficacy. We also learned thatthe studies lacked uniformity both in which agegroups constituted children and which behaviorwas considered suicidal.”

A 2006 meta-analysis by Hall and Lucke81

reviewed the evidence on the effects of SSRIsand their relationship to decreased suicide ratesin the population as well as increased suiciderates in some individuals early in their treatment.They found that SSRIs increase suicidal ideationcompared with placebo but that observationalstudies suggest that SSRIs do not increase suiciderisk to a greater degree than older, non-SSRI anti-depressants. If SSRIs truly increase suicide risk insome patients, then the number of additionaldeaths is very small, since ecologic studies havegenerally found that suicide mortality hasdeclined (or at least not increased) as SSRI usehas increased substantially in the United Statessince their breakthrough in the 1980s.81

Simon and colleagues82 evaluated population-based data to evaluate the risk of suicide deathand serious suicide attempt in relation to the ini-tiation of antidepressant treatment with SSRIs.The risk of death by suicide was not found tobe significantly higher in the month after startingmedication compared with the subsequentmonths of pharmacotherapy. The risk of suicideattempt was found to be highest in the monthbefore starting antidepressant treatment anddeclined progressively after starting medica-tion.82 Available data to date do not indicatea significant increase in risk of suicide or serioussuicide attempt after starting treatment withnewer antidepressant drugs.

Apter and colleagues83 conducted a double-blinded trial of potential suicidal events bycomparing incidence rates between 642 paroxe-tine- and 549 placebo-treated pediatric patients.They determined that suicide-related eventsoccurred more often in paroxetine-treated (22 of642; 3.4%) than placebo-treated groups (5 of 549;0.9%) with an odds ratio of 3.86. All suicide-related events occurred in adolescents of at least12 years of age, except for 1 of 156 paroxetine-treated children, and all suicide attempts

occurred in patients with major depressive disor-der; few suicide-related events occurred inpatients with solely a primary anxiety disorder.They concluded that adolescents treated withparoxetine showed an increased risk of suicide-related events, yet suicidality rating scales usedin the study did not show this risk difference.83

The presence of uncontrolled suicide risk factors,the relatively low incidence of these events, andtheir predominance in adolescents with majordepressive disorder make it difficult to identifya single cause for suicidality in these pediatricpatients.

Olfson and colleagues79 conducted a matchedcase-control study on Medicaid recipients fromall 50 US states who had received inpatient treat-ment for major depression. In adults aged 19–64years, antidepressant (SSRI) drug treatment wasnot significantly associated with suicide attempts(odds ratio, 1.10) or suicide deaths (odds ratio,0.90). However, in children and adolescents aged6–18 years, antidepressant drug treatment wassignificantly associated with suicide attempts(odds ratio, 1.52) and suicide deaths (odds ratio,15.62). The authors concluded that, in thesehigh-risk patients, antidepressant drug treatmentdoes not seem to be related to suicide attemptsand death in adults but might be related in chil-dren and adolescents.79

Juurlink and colleagues84 explored the rela-tionship between the initiation of therapy withSSRIs and completed suicide in older patients.In their study, during the first month of therapy,SSRIs were associated with a nearly five-foldhigher risk of completed suicide compared withother antidepressants (adjusted odds ratio, 4.8).The risk was believed to be independent of arecent diagnosis of depression or the receipt ofpsychiatric care, and suicides of a violent naturewere distinctly more common during SSRI ther-apy. No disproportionate suicide risk was seenduring the second and subsequent months oftreatment with SSRI antidepressants, and theabsolute risk of suicide with all antidepressantswas low.84 The authors concluded that initiationof SSRI therapy is associated with an increasedrisk of suicide during the first month of therapycompared with other antidepressants, yet theabsolute risk is low, suggesting that an idiosyn-cratic response to these agents may provokesuicide in a vulnerable subgroup of patients.84

Conventional wisdom has stressed that treat-ment of major depressive disorder with SSRIsmay increase the risk of impulsive acts includingsuicide, whereas data from epidemiologic studiessuggest that the effect of SSRIs in elderly persons

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may actually be beneficial. Elderly depressedpatients treated with antidepressants may be ata reduced risk of attempting suicide, yet thesefindings need support from rigorous prospectiverandomized trials.85

Conclusions

Whether a male patient will attempt suicide isimpossible to predict, even in cases of majordepressive disorder and other psychiatric ill-nesses. Clinicians are urged to screen for high-risk behaviors and depression when indicated,then to consider asking first open-ended and thendirected questions about suicidal intent when-ever suspicion is present. The importance offorming a meaningful rapport with male patientsto ensure a bidirectional level of comfort withcommunication is paramount.

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