Chapter 43. Suicide

Robert I. Simon, M.D.
DOI: 10.1176/appi.books.9781585623402.318736



There are two kinds of clinical psychiatrists: those who have had patient suicides, and those who will have patient suicides. Every patient suicide is also a tragedy for the clinician and for the suicide survivors. Patient suicide is an occupational hazard of psychiatric practice, accompanied by increased malpractice liability exposure (see Figure 41–1 in Chapter 41, "Psychiatry and the Law," by Simon and Shuman). The only way to avoid patient suicide attempts or patient suicides is to not treat patients.

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TABLE 43–1. Suicide statistics, United States (2004)
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TABLE 43–2. Systematic suicide risk assessment: conceptual model
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TABLE 43–3. Examples of modifiable and treatable suicide risk factors
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TABLE 43–4. Suicide risk associated with various mental and physical disorders
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TABLE 43–5. Basic elements of clinically based risk management
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TABLE 43–6. Sample suicide risk assessment note: contents
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Systematic suicide risk assessment informs treatment and management for patients at risk for suicide. It is secondarily a risk management technique.

Treatable and modifiable acute suicide risk factors should be identified early and treated aggressively.

Systematic suicide assessment identifies and weights the clinical importance of both risk and preventive factors.

Suicide risk assessment is a process, not an event. Psychiatric inpatients should have suicide risk assessments conducted at admission and discharge and at other important clinical junctures during treatment.

Suicide prevention contracts must not take the place of conducting systematic suicide risk assessments.

Contemporaneous documentation of suicide risk assessments is good clinical care and standard practice.

Systematic suicide risk assessment performed at the time of discharge informs the patient's postdischarge plan.

During the treatment of patients at significant risk for suicide, it may be necessary to contact family members or others to facilitate hospitalization, to mobilize support, and to acquire information of clinical importance to the clinician. Whenever possible, this should be done with the patient's permission.

Suicide risk assessment is the responsibility of the psychiatrist. It should not be delegated to others.

The treatment and management of the patient at risk for suicide require the clinician's full commitment of time and effort, despite denial of services and cost containment policies of third-party payers.


Amchin J, Wettstein RM, Roth LH: Suicide, ethics, and the law, in Suicide Over the Life Cycle. Edited by Blumenthal SJ, Kupfer DJ. Washington, DC, American Psychiatric Press, 1990, pp 637–663
American Academy of Child and Adolescent Psychiatry: Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry 40 (7 suppl):24S–51S, 2001a
American Academy of Child and Adolescent Psychiatry: Summary of the practice parameters for the assessment and treatment of children and adolescents with suicidal behaviors. J Am Acad Child Adolesc Psychiatry 40:495–499, 2001b
American Association of Suicidology: Suicide Statistics Archive 1996–2002. Available at: http://www.suicideinfo.ca/csp/90/aspx. Accessed February 5, 2006.
American Psychiatric Association: Practice Guideline for the Treatment of Patients with HIV/AIDS. Washington, DC, American Psychiatric Association, 2000
American Psychiatric Association: The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. A Task Force Report of the American Psychiatric Association, 2nd Edition. Edited by Weiner RD. Washington, DC, American Psychiatric Association, 2001
American Psychiatric Association: Practice guidelines for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160 (suppl):1–60, 2003
Angst F, Stassen HH, Clayton PJ, et al: Mortality of patients with mood disorders: follow-up over 34–38 years. J Affect Disord 68:167–181, 2002
Ash P: Children and adolescents, in The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Edited by Simon RI, Hales RE. Washington, DC, American Psychiatric Publishing, 2006, pp 35–56
Baldessarini RJ: Lithium effects on depression and suicide. J Clin Psychiatry (visuals), January 2003
Baldessarini RJ, Tondo L, Henner J: Treating the suicidal patient with bipolar disorder: reducing suicide risks with lithium. Ann NY Acad Sci 932:24–38, 2001
Barraclough B, Bunch J, Nelson B, et al: A hundred cases of suicide: clinical aspects. Br J Psychiatry 125:355–373, 1974
Bateman AW, Fonagy P: Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment. Oxford, England, Oxford University Press, 2000
Bateman AW, Fonagy P: Mentalization-based treatment of BPD. J Personal Disord 18:36–51, 2004
Beck AT, Steer RA, Kovacs M, et al: Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry 142:559–562, 1985
Beck AT, Brown G, Berchick RJ, et al: Relationship between hopelessness and ultimate suicide: a replication with psychiatric outpatients. Am J Psychiatry 147:190–195, 1990
Beck AT, Steer RA, Ranieri WF: Scale for suicidal ideation: psychometric properties of a self-report version. J Clin Psychol 44:499–505, 1998
Bongar B, Maris RW, Bertram AL, et al: Outpatient standards of care and the suicidal patient. Suicide Life Threat Behav 22:453–478, 1992
Brent DA: Assessment and treatment of the youthful suicidal patient. Ann NY Acad Sci 932:106–131, 2001
Brent DA, Bridge J, Johnson BA, et al: Suicidal behavior runs in families. Arch Gen Psychiatry 53:1145–1152, 1996
Brent DA, Oquendo M, Birmaher B, et al: Familial pathways to early onset suicide attempt. Arch Gen Psychiatry 59:801–807, 2002
Brodsky BS, Malone KM, Ellis SP, et al: Characteristics of borderline personality disorder associated with suicidal behavior. Am J Psychiatry 154:1715–1719, 1997
Brown GK, Ten Have T, Henriques GR, et al: Cognitive therapy for the prevention of suicide attempts. JAMA 294:536–570, 2005
Busch KA, Clark DC, Fawcett J, et al: Clinical features of inpatient suicide. Psychiatr Ann 23:256–262, 1993
Chiles JA, Strosahl KD: Clinical Manual for Assessment and Treatment of Suicidal Patients. Washington, DC, American Psychiatric Publishing, 2005
Clark DC, Fawcett J: An empirically based model of suicide risk assessment of patients with affective disorders, in Suicide and Clinical Practice. Edited by Jacobs DJ. Washington, DC, American Psychiatric Association, 1999, pp 55–73
Conwell Y, Duberstein PR: Suicide in elders. Ann NY Acad Sci 932:132–150, 2001
Dervic K, Oquendo MA, Grunebaum MF, et al: Religious affiliation and suicide attempt. Am J Psychiatry 161:2303–2308, 2004
Dube SR, Anda RF, Felitti VJ, et al: Childhood abuse, household dysfunction and the risk of attempted suicide throughout the lifespan: findings from the Adverse Childhood Experiences Study. JAMA 286:3089–3096, 2001
Duberstein P, Conwell Y: Personality disorders and completed suicide: a methodological and conceptual review. Clinical Psychology: Science and Practice 4:359–376, 1997
Egan MP: Contracting for safety: a concept analysis. Crisis 18:23, 1997
Farwell v. Un, 902 F.2d 282 (4th Cir. 1990)
Fawcett J: Treating impulsivity and anxiety in the suicidal patient. Ann NY Acad Sci 932:94–105, 2001
Fawcett J, Scheftner WA, Fogg L, et al: Time-related predictors of suicide in major affective disorder. Am J Psychiatry 147:1189–1194, 1990
Fawcett J, Clark DC, Busch KA: Assessing and treating the patient at suicide risk. Psychiatr Ann 23:244–255, 1993
Fawcett J, Busch KA, Jacobs DG: Clinical correlates of inpatient suicide. J Clin Psychiatry 64:14–19, 2003
Gabbard GO, Allison SE: Psychodynamic treatment, in The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Edited by Simon RI, Hales RE. Washington, DC, American Psychiatric Publishing, 2006, pp 221–234
Gelenberg AJ, Chesen CL: How fast are antidepressants? J Clin Psychiatry 61:712–721, 2000
Gibbons RD, Brown CH, Hur K, et al: Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry 164:1356–1363, 2007
Gitlin MJ: A psychiatrist's reaction to a patient's suicide (clinical case conference). Am J Psychiatry 156:1630–1634, 1999
Goldsmith SK, Pellman TC, Kleinman AM, et al (eds): Reducing Suicide: A National Imperative. Washington, DC, National Academies Press, 2001
Guthrie E, Kapur N, Mackway-Jones K, et al: Randomized controlled trial of brief psychological intervention after deliberate self-poisoning. BMJ 323:135–138, 2001
Guthrie E, Kapur N, Mackway-Jones K, et al: Predictors of outcome following brief psychodynamic-interpersonal therapy deliberate self-poisoning. Aust N Z J Psychiatry 37:532–536, 2003
Hall RC, Platt DE, Hall RC: Suicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempts: evaluation of suicide risk in a time of managed care. Psychosomatics 40:18–27, 1999
Hammad TA, Laughren T, Raloosin J: Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 63:332–339, 2006
Harris CE, Barraclough B: Suicide as an outcome for mental disorders. Br J Psychiatry 170:205–228, 1997
Hawton K, Townsend E, Arensman E, et al: Psychosocial and pharmacological treatments for deliberate self-harm. Cochrane Database Syst Rev (2):CD001764, 2005
Heikkinen ME, Henriksson MM, Erkki T, et al: Recent life events and suicide in personality disorders. J Nerv Ment Dis 185:373–381, 1997
Hendin H, Lipschitz A, Maltsberger JT, et al: Therapists' reactions to patients' suicides. Am J Psychiatry 157:2022–2027, 2000
Isacsson G: Suicide prevention: a medical breakthrough? Acta Psychiatr Scand 102:113–117, 2000
Isometsa ET, Lonnqvist JK: Suicide attempts preceding completed suicide. Br J Psychiatry 173:531–535, 1998
Isometsa ET, Heikkinen ME, Martunen MJ, et al: The last appointment before suicide: is suicide intent communicated? Am J Psychiatry 152:919–922, 1995
Isometsa ET, Henriksson ME, Heikkinen ME, et al: Suicide among subjects with personality disorders. Am J Psychiatry 153:667–673, 1996
Jacobs DG, Brewer M, Klein-Benheim M: Suicide assessment: an overview and recommended protocol, in Guide to Suicide Assessment and Intervention. Edited by Jacobs DJ. San Francisco, CA, Jossey-Bass, 1999, pp 3–39
Johnson v. United States, 409 F.Supp. 1283 (M.D. Fla. 1976); revised, 576 F.2d 606 (5th Cir. 1978); cert denied, 451 U.S. 1019 (1981)
Kaplan M, Asnis GM, Lipschitz DS, et al: Suicidal behavior and abuse in psychiatric outpatients. Compr Psychiatry 36:229–235, 1995
Kellner CH, Fink M, Knapp R, et al: Relief of expressed suicidal intent by ECT: a consortium of research in ECT study. Am J Psychiatry 162:977–982, 2005
Kessing LV: Subtypes of depressive episodes according to ICD-10: prediction of risk of relapse and suicide. Psychopathology 36:285–291, 2003
Kessler RC, Borges G, Walters EE: Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 55:617–626, 1999
Kim HF, Marangell LB, Yudofsky SC: Pharmacological treatment and electroconvulsive therapy, in The American Psychiatric Publishing Textbook of Suicide and Management. Edited by Simon RI, Hales RE. Washington, DC, American Psychiatric Publishing, 2006, pp 199–220
Lieberman DZ, Resnik HLP, Holder-Perkins V: Environmental risk factors in hospital suicide. Suicide Life Threat Behav 34:448–453, 2004
Linehan MM: Cognitive Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993
Linehan MM, Goodstein JL, Nielsen SL, et al: Reasons for staying alive when you are thinking of killing yourself: the Reasons for Living Inventory. J Consult Clin Psychol 51:276–286, 1983
Linehan MM, Comtois KA, Murray AM, et al: Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 63:757–766, 2006
Loebel JP: Completed suicide in late life. Psychiatr Serv 56:260–262, 2005
Malone KM, Haas GL, Sweeney JA, et al: Major depression and the risk of attempted suicide. J Affect Disord 34:173–185–1995a
Malone KM, Szanto K, Corbitt EM, et al: Clinical assessment versus research methods in the assessment of suicidal behavior. Am J Psychiatry 152:1601–1607, 1995b
Mann JJ, Waternaux C, Haas GL, et al: Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 156:181–189, 1999
Mann JJ, Brent DA, Arango V: The neurobiology and genetics of suicide and suicide attempts: a focus on the serotonergic system. Neuropsychopharmacology 24:467–477, 2001
Marzuk PM, Tardiff K, Leon AC, et al: HIV seroprevalence among suicide victims in New York City, 1991–1993. Am J Psychiatry 154:1720–1725, 1997
Mass. Gen. Laws, Ch. 233, Sec 23D (1986)
Mays D: Structured assessment methods may improve suicide prevention. Psychiatr Ann 34:367–372, 2004
Meltzer HY: Treatment of suicidality in schizophrenia. Ann NY Acad Sci 932:44–58, 2001
Meltzer HY, Alphs L, Green AI, et al: Clozapine treatment for suicidality in schizophrenia. Arch Gen Psychiatry 60:82–91, 2003
Metzner JL, Hayes LM: Suicide prevention in jails and prisons, in The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Edited by Simon RI, Hales RE. Washington, DC, American Psychiatric Publishing, 2006, pp 139–156
Miller MC, Jacobs, DG, Gutheil TG: Talisman or taboo: the controversy of the suicide prevention contract. Harv Rev Psychiatry 6:78–87, 1998
Monahan J, Steadman HJ: Violent storms and violent people: how meteorology can inform risk communication in mental health law. Am J Psychol 51:931–938, 1996
Murphy GE, Wetzel RD, Robins E, et al: Multiple risk factors predict suicide in alcoholism. Arch Gen Psychiatry 49:459–462, 1992
National Center for Injury Prevention and Control: Suicide fact sheet. Available at: http://www.cdc.gov/ncipc/factsheets/suifacts.htm. Accessed February 5, 2006.
Oquendo MA, Halberstam, Mann JJ: Risk factors for suicidal behavior: the utility and limitation of research instruments, in Standardized Evaluation in Clinical Practice. Edited by First MB (Review of Psychiatry Series, Vol 22; Oldham JM and Riba MB, series eds). Washington, DC, American Psychiatric Publishing, 2003, pp 103–130
Ostamo A, Lonnqvist J: Excess mortality of suicide attempters. Soc Psychiatry Psychiatr Epidemiol 36:29–35, 2001
Palmer BA, Pankratz S, Bostwick JM: The lifetime risk of suicide in schizophrenia. Arch Gen Psychiatry 62:247–253, 2005
Pokorny AD: Predictions of suicide in psychiatric patients: report of a prospective study. Arch Gen Psychiatry 40:249–257, 1983
Pokorny AD: Suicide prediction revisited. Suicide Life Threat Behav 23:1–10, 1993
Prudic J, Sackheim H: Electroconvulsive therapy and suicide risk. J Clin Psychiatry 60 (suppl):104–110, 1999
Radomsky ED, Haas GL, Mann JJ, et al: Suicidal behavior in patients with schizophrenia and other psychotic disorders. Am J Psychiatry 156:1590–1595, 1999
Regehr C, Gutheil TG: Apology, justice and trauma recovery. J Am Acad Psychiatry Law 30:425–429, 2002
Resnick PJ: Recognizing that the suicidal patient views you as an adversary. Current Psychiatry 1:8, 2002
Robins E: The Final Months: Study of the Lives of 134 Persons Who Committed Suicide. New York, Oxford University Press, 1981
Rudd MD, Joiner T, Rajab MH: Treating Suicidal Behavior: An Effective, Time-Limited Approach. New York, Guilford, 2001
Sareen J, Cox BJ, Afifi TO, et al: Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults. Arch Gen Psychiatry 62:1249–1257, 2005
Scheiber SC, Kramer TSM, Adamowski SE: Core Competence for Psychiatric Practice: What Clinicians Need to Know. Washington, DC, American Psychiatric Publishing, 2003
Schulsinger F, Kety SS, Rosenthal D, et al: A family study of suicide, in Origins, Prevention and Treatment of Affective Disorders. Edited by Schou M, Stromgen F. London, England, Academic Press, 1979, pp 277–287
Sharma V: Retrospective controlled study of inpatient ECT: does it prevent suicide? J Affect Disord 56:183–187, 1999
Shea SC: The delicate art of eliciting suicidal ideation. Psychiatr Ann 34:385–400, 2004
Silk K: Split (collaborative) treatment for patients with personality disorders. Psychiatr Ann 31:615–622, 2001
Silverman MM: Understanding suicide in the 21st century. Preventing Suicide: The National Journal 2(2), March/April 2003
Simon GE, Savarino J, Opersklaski B, et al: Suicide risk during antidepressant treatment. Am J Psychiatry 163:41–47, 2006
Simon RI: Coping strategies for the "unduly" defensive psychiatrist. Int J Med Law 4:551–561, 1985
Simon RI: Clinical Psychiatry and the Law, 2nd Edition. Washington, DC, American Psychiatric Press, 1992
Simon RI: The suicidal patient, in The Mental Health Practitioner and the Law: A Comprehensive Handbook. Edited by Lifson LE, Simon RI. Cambridge, MA, Harvard University Press, 1998, pp 329–343
Simon RI: The suicide prevention contract: clinical, legal and risk management issues. J Am Acad Psychiatry Law 27:445–450, 1999
Simon RI: Taking the "sue" out of suicide: a forensic psychiatrist's perspective. Psychiatr Ann 30:399–4071, 2000
Simon RI: Suicide risk assessment: what is the standard of care? J Am Acad Psychiatry Law 30:340–344, 2002
Simon RI: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC, American Psychiatric Publishing, 2004
Simon RI: Best practices or reasonable care? J Am Acad Psychiatry Law 33:8–11, 2005
Simon RI: Patient safety versus freedom of movement: coping with uncertainty, in The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Edited by Simon RI, Hales RE. Washington, DC, American Psychiatric Publishing, 2006, pp 423–439
Simon RI: Gun safety management with patients at risk for suicide. Suicide Life Threat Behav 37:518–526, 2007
Simon RI, Shuman DW: The standard of care in suicide risk assessment: an elusive concept. CNS Spectr 11:442–445, 2006
Stanford EJ, Goetz RR, Bloom JD: The no harm contract in the emergency assessment of suicidal risk. J Clin Psychiatry 55:344–348, 1994
Slovenko R: Psychiatry in Law/Law in Psychiatry. New York, Brunner-Routledge, 2002
Trémeau F, Staner L, Duval F, et al: Suicide attempts and family history of suicide in three psychiatric populations. Suicide Life Threat Behav 35:702–713, 2005
Warman DM, Forman E, Henriques GR, et al: Suicidality and psychosis: beyond depression and hopelessness. Suicide Life Threat Behav 34:77–86, 2004
Wintemute GJ, Parham CA, Beaumont JJ, et al: Mortality among recent purchasers of handguns. N Engl J Med 341:1583–1589, 1999

CME Activity

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Sample questions:
Suicide statistics help to give the clinician a sense of the extent of this clinical problem, and, when put into context, may guide clinical risk assessment and decision making. Which of the following statements regarding suicide in the United States is false?
Differentiating short-term from long-term risk factors for suicide may be important, because modifying just a few short-term risk factors may significantly reduce a patient's risk for suicide. Among the suicide risk factors identified in a 10-year prospective study of patients with affective disorders (Fawcett et al. 1990), which of the following was considered to be a long-term suicide risk factor rather than a short-term one?
The rates of suicide associated with different psychiatric illnesses must be considered in clinical care. Which of the following statements about suicidality in various psychiatric disorders is false?
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