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Jacobs DG. A 52-Year-Old Suicidal Man. JAMA. 2000;283(20):2693–2699. doi:10.1001/jama.283.20.2693
Author Affiliation: Dr Jacobs is Associate Clinical Professor of Psychiatry, Harvard Medical School, Boston, and Executive Director, Screening for Mental Health, Wellesley Hills, Mass.
Clinical Crossroads Section Editor: Margaret
A. Winker, MD, Deputy Editor.
DR PARKER: Mr D is a 52-year-old man who, in
despair, almost jumped in front of a moving train. He attributes this episode
to gambling debts piled up in the prior 6 months and the ensuing conflict
with his family. He is a resident of Boston and has health insurance through
his blue-collar job.
Mr D describes a history of depression dating to his youth. He grew
up in a "tough" family, with a father who gambled and drank and brothers who
used drugs and alcohol. He has had suicidal thoughts on many occasions but
strongly contemplated suicide only once before when he was briefly held in
solitary confinement while in jail for a minor crime.
Despite attending a gambling addiction program, he relapsed and lost
several thousand dollars gambling. His problem was magnified because he lost
another individual's money as well. A family member was terminally ill at
this time, and Mr D got little food or sleep. He considered staging his own
accidental death so his family could collect on his life insurance. He denied
any access to firearms. His family encouraged him to voluntarily admit himself
to the psychiatric ward.
Mr D described his mood as "hopeless," with diminished appetite, poor
sleeping, and decreased energy and ability to concentrate. He described feelings
of shame and guilt. When asked why he did not jump, he answered that his religious
beliefs held him back. In addition, a relative had committed suicide some
years ago, and he felt some obligation to "help others prevent that."
Mr D has no prior psychiatric hospitalizations. He denied current alcohol
use and admitted to past use of marijuana and LSD as a teenager. He quit smoking
cigarettes many years ago. Mr D erratically attends a gambling addiction program
and is in treatment with a psychiatrist who monitors his medication use. His
past medical history is unremarkable.
Mr D completed high school and some college, has been married for 3
decades, and has children in their early 20s who are "doing well."
He is currently taking fluoxetine hydrochloride, 40 mg daily, and trazodone
hydrochloride, 50 mg daily.
On examination, Mr D exhibits a depressed affect with slowed speech.
He tends to avoid eye contact, although he became more engaged throughout
the interview. There was no psychotic content. He did not know when he would
be ready to leave the psychiatric ward.
I'm from a family that doesn't show emotions. A relative hung himself
when he was a teenager. I think I was depressed for a long time after that.
Then I lost a job, and I had all this leisure time. I have a history of having
a little violence in my background. I left home when I was still a kid.
I was what they call a hippie. I'm the opposite now. My drug of choice
was LSD. I used to hitchhike all over the place. I lived on the streets. I
got picked up, and it was a long weekend. And I had a beef in jail, and I
ended up in the hole. I did a lot of thinking in there, and I think I almost
killed myself right there. I don't know why I didn't.
I started gambling, and the old saying when you're gambling is, "If
I ever get even, I'll quit." Well, a few years ago, I got even and I quit.
Then I broke out, and I got even and I said, "I'll quit." You get out of control.
It's a compulsive thing. Everywhere I go, my compulsion is gambling. I mean,
every member of my family gambles. "You know the number last night? There's
$20 million in the jackpot. You going down to the race track?" My mother was
a gambler, my father was an alcoholic gambler.
I got into such a financial hole, I was thinking of going out and getting
even by pulling an armed robbery or something. And I got scared. That wasn't
the way out. It is, and it isn't. I just started over the past month thinking
whether to do that, or you know, you're on the train or waiting for the train,
and you're looking at it saying, "Should I just jump in front of it?" I came
within inches of jumping. I had a [feeling] as if I was seesawing . . . "Should
I, shouldn't I?" And then I said, "No, I can't." I started thinking about
the family, and I didn't do it. Then I started thinking about ways of doing
it, so my wife would get the insurance and stuff. The biggest worry for me
right now is shaming members of my family, because we don't do this, you know.
The past 2 years have been very hectic. Even when I wasn't gambling
I was getting into these uncontrollable rages. Good friends of mine would
come up to me and say, "Gee, pal, you're losing control."
Around our way they have a saying, if you put time between a crime,
that will be less time you do. And like, put time between the thoughts then
maybe you won't do . . . what I'm looking at.
I hope you translate whatever I'm saying to benefit maybe someone else.
What is the extent of the problem of suicide in the United States for
adults? How do we evaluate suicide risk? What are particular warning signs,
and how can the primary care physician identify patients in the outpatient
setting who may be considering suicide? Do different methods of attempting
suicide (eg, shooting, hanging, overdose, or jumping) have different implications?
What are the elements of an evaluation of a suicidal patient? What role do
medications play? What would you recommend for Mr D?
DR JACOBS: Specific suicide rates vary according
to age and sex, but overall, suicide is the eighth leading cause of death
nationwide. Of people who complete suicide, 90% to 93% have at least 1 major
psychiatric disorder, usually affective disorder, schizophrenia, or alcoholism.
Frequently they have comorbid mental illnesses. Men complete suicide more
often than women (4:1), but women make more suicide attempts.1
Approximately 30,000 people commit suicide each year, which represents
1.4% of all deaths in the United States. The surgeon general recently identified
suicide as a public health problem and urged the nation to focus on suicide
as a national health issue. Statistics driving this national call to action
focus on the increase in suicide rates among teenagers, suicide's rise from
the ninth to the eighth leading cause of death nationwide within the last
year, and the deep secrecy associated with suicide.2
Suicide profoundly affects the survivors, and, in the case of Mr D,
this appears to be one of his reasons for participating in the interview.
Mr D indicated that the cluster of suicides among teenagers in the mid 1990s,3 which included his relative, was so painful for him
that he agreed to take part in this case conference. He hoped his participation
in the difficult interview would help physicians better understand the issue
of suicide and help them prevent others from committing suicide.
I recommend using a comprehensive suicide assessment protocol (Table 1).1
Many risk factors have been identified as being associated with suicide (Table 2). However, none of the risk factors,
alone or in combination, are specific enough to predict which individuals
will complete suicide. Although we cannot predict who will complete suicide,
we can assess an individual's level of risk for suicide, and this helps us
Risk factors for suicide fall into 2 categories: predisposing factors
and potentiating factors. Other authors have made similar distinctions, dividing
risk factors into distal (foundation or root cause) and proximal factors (precipitating
or triggering factors).5 The predisposing (distal)
risk factors include the major psychiatric syndromes of depression or affective
illness, schizophrenia, alcoholism or substance abuse, and certain personality
disorders. Pathological gambling, present in Mr D's case, is an addiction
that increases risk in a manner similar to other addictive illnesses.6,7
Specific risk factors are associated with each of the diagnoses mentioned
above. The number 1 distal risk factor for suicide is affective disorder (mood
disorder), with more than 60% of individuals who complete suicide having some
form of affective disorder.8 Anxiety and panic
symptoms that occur in the context of a major depression also increase suicide
risk. This information is relevant for physicians of all disciplines because
both depression and the symptoms of anxiety are risk factors that are modifiable
through interventions such as medication, psychotherapy, and relaxation techniques.9
Based on Mr D's clinical presentation, he would be considered a suicide
risk (Table 2). He is male, had
a drop in economic status, had a psychiatric diagnosis with comorbidity, was
in psychological turmoil, and had suicidal ideation. In addition, he has antisocial
traits, which increase suicide risk. His personality traits are likely to
make him chronically vulnerable to suicidal thoughts when he feels humiliated
or deeply ashamed.
Potentiating risk factors include situational stressors that, when combined
with a predisposition to suicide from mental illness, increase the individual's
vulnerability to suicide. The potentiating or proximal factors include: physical
illness, intoxication, a toxic family or social milieu, access to guns or
other methods of suicide, and intense life stresses or crises.1
In general, the risk factors for suicide are additive such that the more risk
factors an individual has, the greater the risk of suicide.5
The obvious potentiating risk factors in Mr D's life are the financial
difficulties and estrangement from his family that result from his pathological
Mr D's symptoms would have been detected by a primary care physician
using a depression screening tool, even if the physician had not first independently
asked about suicidal ideation. In fact, a screening tool would have been a
useful avenue for opening such a dialogue.
In the last 10 years, depression screening has proven to be an effective
and efficient way of identifying those with undiagnosed depressive illness
and is a useful tool for the primary care physician attempting to ascertain
the likelihood and severity of depression and the presence of suicidal thoughts.10 Besides identifying possible serious cases of depression
that can lead to suicide, most depression scales include a specific question
about suicidal ideation.
A nonprofit organization, Screening for Mental Health, through its annual
National Depression Screening Day (NDSD)11-13
has provided an easy-to-use screening form (the HANDS, Harvard Department
of Psychiatry/National Depression Screening Day Scale, Figure 1) designed to minimize physician time by quickly identifying
patients who have a positive score or who endorse a suicide question. (The
screening form is filled out by the patient in the waiting room and scored
by a secretary or other staff. Completed forms are placed in the patient's
file for the physician's review.)
The results of this screening effort are striking. Fully 22% of primary
care patients had a positive score for depression, including 45% who have
received treatment for alcohol abuse, 28% of those with stroke, 19% of those
with cancer, 23% with diabetes, 27% with arthritis, and 23% of those with
heart disease (unpublished data analyzed by the National Institute of Mental
Health from completed screening forms collected by Screening for Mental Health
from participating primary care clinicians in 1999). These findings underscore
the need for depression screening in primary care settings and the ease with
which it can be incorporated. Depression screening is simple, cost-effective,
reliable, and potentially money saving because it can identify previously
unidentified depression without the time-consuming and costly burden of attempting
to diagnose vague medical complaints that often bring the patient into the
office for numerous visits.
Certain clinical factors should alert the clinician to the possibility
of depression,10 and screening may be particularly
useful in patients who:
have experienced a recent loss or are undergoing severe stress;
report vague somatic symptoms (insomnia, headaches, stomachaches);
express any of the somatic or emotional symptoms of depression;
have a family history of depression, suicide, or mental illness;
have a history of self-medicating behavior, including alcohol
have a history of self-destructive behavior;
are currently taking certain medications, particularly antihypertensives,
hormones, histamine-2 receptor blockers, anticonvulsants, levodopa, or β-blockers;
are suffering from a major physical illness such as stroke, cancer,
are in the postpartum period;
have a history of diagnosed depression.
By identifying and addressing depression, primary care physicians may
also identify suicidal thoughts and behavior.
Multiple screening tools exist, including HANDS.14
This scale is used in the National Depression Screening Day Primary Care Outreach.
It was specifically created to be a brief, easy-to-score, self-report form
applicable to a variety of settings that performs at least as well as longer,
more complicated scales, and addresses the critical issues of sensitivity
and specificity. The HANDS (Figure 1)
has been validated for detecting the likelihood of clinical depression based
on criteria for a major depressive episode from the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Scores of 9 or greater give a sensitivity of at least 95%
and indicate that the patient should be evaluated for the likelihood of a
major depressive episode. Specificity in the general population is 94%.14
Primary care providers may worry that asking about suicide will introduce
the idea into their patient's minds. My clinical experience is that the opposite
is often true. Many patients are relieved when their physician opens a dialogue
about suicide; it gives them the opportunity to discuss a frightening and
troubling subject and offers the physician the opportunity to both assess
the patient and educate him or her about the relationship between suicidal
thoughts and depression in particular. By being direct, the physician offers
hope, providing a lifeline to a suicidal patient, who, because of feelings
of hopelessness, may otherwise become isolated.
People who are experiencing suicidal feelings are almost always ambivalent
in those feelings; they have the simultaneous wish to die and wish to live.15 This ambivalence offers the clinician an opportunity
to intervene and ally with the part of the patient that wishes to live.16 Mr D described his own ambivalence about suicide
by saying "I was seesawing."
If gently and tactfully done, asking about suicidal intent can encourage
a patient to reveal specific suicidal plans. This can lead to a discussion
of alternatives to suicide, which the patient can be encouraged to consider.
I believe an inquiry into suicide should be conducted whenever the physician
is concerned about suicide risk because of the patient's depression, references
to hopelessness or lack of a future, or a positive response to a suicide question
on a screening form. The following questions may be used to inquire about
a patient's suicidal thoughts.17
Do you ever get so depressed that you think life is not worth
Do you think of hurting yourself or taking your own life?
Do you have a plan?
Do you have the means to follow through with the plan?
Have you ever attempted suicide?
Positive responses to any of the questions should indicate to the primary
care physician that the patient is at risk for suicide. The more specific
the patient is with regard to a plan and the more lethal the plan is, the
more severe the risk. For example, attempts involving shooting or hanging
are more likely to be lethal than overdoses or wrist cutting.1
If a patient has even passive suicidal ideation (eg, "I sometimes wish I would
just die in my sleep. I think that my family would be better off without me"),
referral for a psychiatric evaluation is the most prudent course. If the patient
is actively and imminently suicidal (eg, "Yeah, I've been thinking about dying.
I had my gun out this morning. I don't know why I didn't just do it then"),
seek emergency psychiatric evaluation.
Mr D experienced suicidal ideation with a very lethal plan. His description
of being "inches" from jumping in front of a train is consistent with an aborted
suicide attempt, which falls somewhere between suicidal ideation and a suicide
attempt in terms of risk severity.18 If he
had presented to his internist's office recently having contemplated jumping
in front of a train, his physician would have needed to seek an emergency
psychiatric evaluation. The fact that Mr D also was considering alternate
methods of suicide increased his suicidal risk. In addition, Mr D demonstrated
shame and intolerable rage. Fortunately, the presence of ambivalence and deterrents
(primarily his wife and family and his religious beliefs) have positive therapeutic
The fourth component of assessing suicidality entails sorting out disorder-based
suicidality from personality-based suicidality. Disorder-based suicidality
relates to an Axis I disorder (a major psychiatric syndrome [DSM-IV]), such as depression, and consists of prominent feelings of
anguish or pain and a wish to escape. The risk tends to be more acute. There
is a compulsive, driven quality. The options for treatment include medication,
hospitalization, supportive psychotherapy, or electroconvulsive therapy.
Personality-based suicidality results from feelings of anger, aggression,
or vengeance. The risk tends to be more chronic. There is also a complicating
impulsive quality to it. When possible, the patient should be accorded as
much responsibility as possible. This can be given only in the context of
assessing the treatment alliance. Regardless of the basis of suicidality,
primary care physicians treating patients who have the ability to carry out
a suicide plan should seek emergency psychiatric consultation, voluntary psychiatric
admission, or both. If patients are unwilling to be admitted for psychiatric
evaluations, the primary care physician should seek the consultation of a
psychiatrist in evaluating the patient. States differ with regard to their
laws pertaining to involuntary commitment.19
Studies of completed suicides show that 75% of victims saw a physician
within 6 months of their suicide and 60%, within 1 month.20
These findings indicate that persons considering suicide appreciate that something
is troubling them and make the effort to see a clinician, but do not or cannot
communicate their suicidal thoughts. Primary care physicians can play a pivotal
role in recognizing suicide potential in their patients.17
At least half of the patients receiving mental health care obtain that care
through their primary care provider.21 In addition
to providing psychiatric treatment, primary care providers are often at the
point of entry into the health care system and decide when the patient needs
psychiatric referral. As responsibility for diagnosing mental illness falls
increasingly under the domain of primary care, it becomes more important for
these clinicians to be informed about mental health disorders and understand
when referral is necessary.22
Medications have proven effective in the treatment of depressive disorders.
Half of people with depression are treated in the medical sector and the other
half treated in the mental health care system.21
I believe it is important when discussing the risks and benefits of antidepressant
medication to educate patients and their families about dosage, the purpose
and expected benefits of the medication, risks and adverse effects, and length
of time for usual response and to emphasize that improvement can be uneven.
The feeling of getting worse again after experiencing some improvement can
be devastating to depressed patients, contributing to hopelessness and probably
increasing suicide risk. If patients have been warned to anticipate that they
will feel better some days and worse on others, then they are less likely
to be overwhelmed by apparent setbacks.23
In recent years, promising reports have been published about the impact
of psychopharmacologic agents on reducing suicide risk. For instance, the
use of benzodiazepines may modify the risk of suicide by reducing anxiety.9 Recent studies have determined that lithium has a
strong, and possibly unique, protective effect against suicidal acts in persons
with major affective disorders and particularly in bipolar forms of manic-depressive
illness.24 Several years ago there was intense
media coverage of a possible link between fluoxetine hydrochloride (Prozac),
suicidal ideation, and other aggressive acts. This question has been carefully
studied and evidence refutes any correlation.25-27
Clozapine treatment can reduce risk of suicidal acts in patients with neuroleptic-resistant
schizophrenia.28 In summary, recent research
seems to support hypotheses that treating psychiatric disorders with appropriate
medications can reduce suicide risk. Primary care physicians, however, should
remember that depressed patients, particularly in the early phase of treatment,
can be at risk for suicide, so that attention should be paid to appropriate
follow-up, patient education, and prescription size. In the end, the therapeutic
patient-caregiver relationship is a critical life-saving treatment component.
In determining the level of intervention for Mr D, his suicidality should
be considered as the combination of his depression (disorder based) and personality
traits (personality based). The hospitalization he had was indicated to stabilize
the crisis and establish a relationship with the therapist or psychiatrist
during the hospitalization. It would be important to review pharmacologic
interventions, and to educate the patient and family about suicide potential
and managing these comorbid illnesses.
In the field of psychiatry, documentation of suicide risk assessment
must be incorporated throughout the entire treatment process to ensure that
the issue has been addressed for other health care professionals reviewing
the medical records and for legal purposes. Useful guideposts for conducting
assessments include: (1) the first psychiatric assessment or admission; (2)
the occurrence of any suicidal behavior or ideation; (3) any noteworthy clinical
change; and (4) any change in level of observation for inpatients, such as
increasing privileges or giving passes before discharge. Physicians must also
plan the frequency of reassessments. This is critical as it acknowledges that
suicidality waxes and wanes. For the primary care physician, documentation
of the suicide assessment is also crucial for clinical and risk management
purposes to demonstrate that the physician has both inquired about suicide
and documented the basis for the treatment decisions. In particular, use of
pejorative terms such as "gesture," should be avoided when documenting suicidal
behavior. Clinicians use the term gesture to describe
patients who perform minor (rather than lethal) self-destructive acts. However,
the fact that the self-destructive act is minor does not mean that the patient
is not suicidal or that the intent was not lethal.
Mr D has several predisposing risk factors for suicide. Because of his
erratic, antisocial personality traits, he needs exterior, sustaining resources
more than most people, yet he is likely to alienate the very people he depends
on for support. The combination of these factors means Mr D has a long-term,
increased risk for suicide, especially an impulsive suicide in response to
Mr D's gambling addiction, almost by definition, sets up crises that
potentiate his risk for suicide. Every time he gambles away more money than
he can afford to lose, he faces financial stress, rejection by his family,
and a further drop in self-esteem. Mr D faces other potentiating risk factors
as well: he has not been sleeping regularly, and a family member is ill. His
high level of risk for suicide was obviously recognized by his physician,
who arranged for his admission to the psychiatric ward.
It was appropriate and necessary to ask Mr D specifically about his
access to guns. Despite his assurances that he did not have a gun and would
never use one on himself, Mr D is obviously at risk for impulsive suicide.
In outpatient planning, it would be prudent to talk to his wife and adult
children about his access to guns. Also, it would be crucial to document the
inquiry about firearms and that Mr D specifically denied having access to
a firearm.19 If a firearm were present, it
would be prudent to document instructions to patient and family.
Mr D described in some detail his aborted suicide attempt when he was
"inches" from jumping in front of a train. He was, however, less than forthcoming
about current or continuing suicidal thoughts. One has to question whether
he is keeping an escape plan to himself. Mr D also implied that his wife does
not know the full extent of his difficulties. Given that his connection with
his wife is probably the single most important factor keeping him alive, this
relationship needs to be addressed.
While some of Mr D's suicidality is attributable to depression, it seems
likely that most of his suicidality at this time is related to his personality
structure and the crises he faces in his personal life. When we see Mr D interviewed,
he is already in inpatient treatment. However, if a primary care physician
examined Mr D, he should refer Mr D for an immediate psychiatric evaluation.
Mr D needs regular suicide assessments until his acute suicidality remits.
Once he is discharged, he should be asked about suicide each time he sees
his physician until he is stable, and his family should be instructed to call
in the event that he starts gambling again or seems more aggressive and threatening.
A central component in managing the chronic nature of Mr D's suicidality
is to educate him and his family about his illness and to develop a working
alliance with Mr D's health care providers. Prudent use of antidepressant
medication will be useful for treating both this depression and reducing his
impulsivity. Encouraging Mr D to be engaged with a gambling addiction program
is an important part of building an additional support structure in his life.
The challenge in caring for a patient like Mr D, who has an addictive disorder
and an affective disorder, as well as elements of a character disorder, is
to be supportive and nonjudgmental yet stress the need for him to take responsibility.
A PHYSICIAN: Tell us about the decision-making
process that brought Mr D into the hospital. I'm still unclear about which
patients I should hospitalize and which I should send to a psychiatrist as
DR JACOBS: If someone has a major psychiatric
disorder with the presence of suicidal ideation and is not involved in a strong
therapeutic relationship, then that person should be hospitalized, at least
briefly. A man who has considered a lethal method, such as jumping onto a
train track, or is thinking of staging an "accident" because of insurance
is at very, very high risk. I think we want to believe that our patients want
help, that they will tell us how they feel. If someone is feeling suicidal,
in my experience, generally they tell us. I've had patients who have talked
about serious suicidality in my office, and then I got nervous or anxious
saying, maybe we need to do something about this. And one patient said, "Well,
Dr Jacobs, if I can't feel suicidal in your office, where else can I feel
it?" If individuals are not ambivalent about their suicide, they will not
communicate their suicidality. . . . However, the good news is that most patients,
even the seriously suicidal, are ambivalent and will communicate their suicidality,
thus allowing an opportunity to intervene, whether by increasing visits, altering
medications, consultation, referral, or hospitalization.
A PHYSICIAN: You mentioned the high suicide
rate in patients with schizophrenia, even higher than in those with depression.
But given command hallucinations and that patients with schizophrenia don't
always communicate as directly, what does the literature now tell us? How
do you sort it out?
DR JACOBS: Eighty percent of suicides are males,
and with schizophrenic patients the proportion of males may even be higher.
The issue of command hallucinations is somewhat problematic. I would hope
that any schizophrenic patient who goes to an emergency department or physician's
office having acute command hallucinations will be hospitalized. Part of the
problem that schizophrenics have in terms of suicide intervention is their
impaired ability to communicate. Because of their repressed affect, they don't
appear to be in the kind of internal turmoil that a typical depressed person
shows. It's sometimes hard to notice the pain of a schizophrenic person unless
the individual is showing some depressive symptoms. Ironically, patients with
good premorbid functioning are more aware of their decline, which places them
at greater risk for suicide.29 Male sex, chronic
relapsing course, and a history of suicide attempts are risk factors for suicide
in that population.
A PHYSICIAN: If the ratio of attempts to completions
is about 20 to 1, how should we think about these attempts? Are people really
that inept at committing suicide, or are they stopping short of a sure thing?
DR JACOBS: Statistically we believe that for
every 23 attempts, there is 1 completion. Most attempts are made by females,
with a ratio of 3 to 1. Clearly more females are attempting suicide and not
completing it. You have to see attempts as part of the ambivalence and as
an opportunity to intervene. The good news is that 90% of people who attempt
suicide do not complete it.1
A PHYSICIAN: Can you comment on the needs of
families who survive a completed suicide and the needs of clinicians whose
patients complete suicide?
DR JACOBS: For the family, the issues are guilt,
anger, and self-blame. Try to reach out and understand where the family is.
There is also a risk-management perspective here, because they can turn that
self-blame onto someone else—sometimes the physician. The myth persists
among the public that suicide should not happen, and if it does happen, someone
did something wrong.
Physicians need to accept that suicides do happen, despite our best
efforts. Suicides are part of the work—just like death in any other
branch of medicine. You can learn from a suicide, but you have to be careful
to avoid confusing feelings of compassion for the family with acknowledging
that you wish you had done something differently. If you feel like that, you
should probably consult with a colleague or speak with a risk manager.
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