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Table 1. Essential Elements Of The History In Potentially Suicidal Patients.

• Current suicidal ideation, intent, and plan (ask specifically about each)

• History of suicide attempts (include date, circumstances, and lethality of method)

• Family history of suicide

• History of mental illness (especially depression, schizophrenia, bipolar disorder, borderline personality, and anxiety disorders)

• Intensity of current depressive symptoms

• Current treatment regimen and response

• Psychotic symptoms (especially auditory command hallucinations, thoughts of external control, and religious preoccupation)

• Alcohol and drug use patterns

• Concurrent medical illnesses, especially debilitating or painful conditions

• Past or present history of violence/aggression

• Recent life stressors (e.g., marital separation, job loss)

• Current living situation (e.g., social supports, availability of weapon)

• Family member contact information to corroborate details and assess safety of home conditions

Adapted from: Frierson RL, Melikian M, Wadman PC. Principles of suicide risk assessment. How to interview depressed patients and tailor treatment. Postgrad Med 2002 Sep;112(3):65-66, 69-71.

pathophysiology of suicide

risk determinants previous suicide attempt major depression recent discharge from psychiatric hospital alcoholism or substance abuse elderly white/male A previous suicide attempt is considered to be the best predictor of a future completed suicide; however, this history alone cannot be used to predict which patients will ultimately commit suicide. About one-third of people who attempt suicide will repeat the attempt within one year, and about 10% of those who threaten or attempt suicide eventually do kill themselves. Suicide is the third leading cause of death in the adolescent population	Useful initial diagnostic tests in patients who have attempted suicide may include an electrocardiogram, acetaminophen level, salicylate level, and blood alcohol level. The ECG can be diagnostic in suicide attempters who present with an altered mental status or unstable vital signs. In particular, tricyclic antidepressant toxicity is suggested by the presence of a rightward axis in the terminal 40-msec of the QRS complex coupled with QRS widening.67 67. Niemann JT, Bessen HA, Rothstein RJ, et al. Electrocardiographic criteria for tricyclic antidepressant cardiotoxicity. Am J Cardiol 1986 May 1;57(13):1154-1159. (Comparative; 25 patients) Table 3. Factors Protective Against Suicide. Compliance with psychiatric medication .Social support . Involvement in a religious group.Being a parent.Positive coping skills.Adequate treatment of chronic pain.Adequate treatment of substance abuse.Adequate follow-up of discharged patients. Source: Goldsmith SK, Pelimar TC, Kleinman AM, et al, eds; Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide Board of Neuroscience and Behavioral Health. Reducing Suicide: A National Imperative. Washington, DC: Institute of Medicine; 2003.	In March 2004, the U.S. Food and Drug Administration issued a statement requiring the manufacturers of several antidepressants (fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram, bupropion, venlafaxine, nefazodone, and mirtazapine) to include a warning statement that recommends close observation of adult and pediatric patients treated with these agents for worsening depression or the emergence of suicidality, particularly at the beginning of therapy or when the dose either increases or decreases.49 Table 2. Risk Factors And Symptoms Associated With Suicide.Epidemiologic factors.Male, white, age greater than 65 years.Widowed or divorced.Living alone; no children under the age of 18 in  the household.Presence of stressful life events.Access to firearms.Psychiatric disorders.Major depression.Substance abuse (particularly alcohol).Schizophrenia.Panic disorder.Borderline personality disorder.In adolescents: impulsive, aggressive, and antisocial behavior; presence of family violence and disruption.Past history.History of previous suicide attempt.Family history of suicide.Symptoms associated with suicide.Hopelessness.Anhedonia.Insomnia.Severe anxiety.Impaired concentration.Psychomotor agitation.Panic attacks Adapted from: Gliatto MF, Rai AK. Evaluation and treatment of patients with suicidal ideation. Am Fam Physician 1999 Mar 15;59(6):1500-1506. Suicidal Patients: Assessing And Managing Patients Presenting With Suicidal Attempts Or Ideation Table 4. SAD PERSONS Scale. Factor                 Points S = Sex (male) 1 A = Age (<19 or >45 years) 1 D = Depression 1 P = Previous suicide attempt 1 E = Ethanol abuse 1 R = Rational thinking loss 1 S = Social supports lacking 1 O = Organized plan 1 N = No spouse 1 S = Sickness (chronic debilitating disease) 1 Score less than 2: discharge with outpatient psychiatric evaluation Score of 3-6: consider for hospitalization or at least very close follow-up Score of 7 or greater: hospitalization Source: Patterson WM, Dohn HH, Bird J, et al. Evaluation of suicidal patients: the SAD PERSONS scale. Psychosomatics 1983 Apr;24(4):343-345, 348-349. The complete psychiatric mental status examination includes the patient’s appearance, behavior, mood, affect, speech, thought process, thought content, insight, and judgment. (affect, attention, language, orientation, memory, visual-spatial ability, and conceptualization) Useful initial diagnostic tests in patients who have attempted suicide may include an electrocardiogram, acetaminophen level, salicylate level, and blood alcohol level.
How's your health?	Self-perception of poor health is associated with a significantly increased risk of suicidal ideation, even in the absence of common mental and physical disorders.47	47. Goodwin R, Olfson M. Self-perception of poor health and suicidal ideation in medical patients. Psychol Med 2002 Oct;32(7):1293-1299. (Prospective; 4007 patients)
How did you come to feel this way?	Eighty-three percent of adolescent patients who had attempted suicide were not previously recognized as suicidal by their primary care physician.	How long have you felt this way?

classifications

mood disorders
substance abuse	Table 6. CAGE Screen For  Alcohol (risk factor for suicide) C = "Have you ever felt you should Cut down on your drinking?" A = "Have people Annoyed you by criticizing your drinking?" G = "Have you ever felt bad or Guilty about your drinking?" E = "Have you ever had a drink as an Eye-opener first thing in the morning to steady your nerves or help a hangover?" Yes to two or more: probable alcohol abuse	mixed ingestions
psychotic disorders
personality disorders		top