Assessing Risk for Imminent Suicide

431 ABSTRACT Most suicide victims see a health professional shortly before their death; yet, at present, clinicians have no tools for identifying those at acute risk. Clinical instruments valuable in predicting suicide over a 10year period were not effective in predicting completed suicides within a period of 6 months. In fact, the difference between chronic and imminent suicide risk has only recently been articulated in the literature. A promising approach is to assess suicide risk along multiple dimensions. In this article, we review an evaluation model that consists of four domains: 1) long-term suicide risk, 2) implicit acceptance of suicide as a solution to problems, 3) acuity of the suicidal state, and 4) clinicians’ emotional response (ie, countertransference) to the acutely suicidal patient. The first domain has already been integrated into clinical practice. The review focuses on the next three dimensions and suggests ways to utilize them in clinical practice. [Psychiatr Ann. 2014; 44(9):431-436.] One of the most difficult determinations clinicians face is whether the chronically suicidal patient in front of them is at risk for imminent suicide. Most suicide victims have pre-existing mental disorders1,2 and see a health professional within the 6 months prior to their suicide;3 yet, at present, no combination of factors effective in assessing chronic suicide risk has demonstrated clinical value in predicting imminent suicide.4 The difference between chronic and imminent suicide risk has only recently been articulated in the literature. Clinical instruments valuable in predicting suicide over a 10-year period were not effective in predicting completed suicides or even suicide attempts within a 6-month period. This discrepancy underscores the need for accurate assessment of acute or imminent suicide risk. The need for a dependable assessment of imminent suicide risk is heightened by pressure from insurance companies to avoid hospital admissions. These pressures will become even more pronounced with the upcoming mass switch to risk contracts, which aim to drastically reduce admission rates (and that may result in the referral of large numbers of patients at elevated suicide risk to outpatient offices). Moreover, these same pressures are likely to lead to the premature discharge of suicidal patients from inpatient psychiatric units. Ironically, completed suicide rates are the highest in the first week after discharge from a psychiatric unit; risk is 100 times higher for men and 300 times higher for women compared with those who were never hospitalized.5 A promising approach is to assess risk along multiple dimensions as shown in Figure 1. Four questions can provide a good baseline for assessing risk: 1. Is this a patient known to be generally at high lifetime risk for suicide (such as a bipolar patient with severe agitated depressive episodes and a history of suicidal ideation, preparations, or attempts6)? Igor Galynker, MD, PhD, is Associate Chairman, Department of Psychiatry, Mount Sinai Beth Israel. Zimri Yaseen, MD, is Attending Psychiatrist, Mount Sinai Beth Israel. Jessica Briggs, BA, is Program Assistant, Department of Psychiatry, Mount Sinai Beth Israel. Address correspondence to: Igor Galynker, MD, PhD, Department of Psychiatry, Mount Sinai Beth Israel, 317 East 17th Street, New York, NY 10003; email: [email protected]. Disclosure: The authors have no relevant financial relationships to disclose. doi: 10.3928/00485713-20140908-07 Assessing Risk for Imminent Suicide