Magazine article Clinical Psychiatry News

Factors for Acute Suicide Risk Are Not Widely Recognized. (Overturning Conventional Wisdom)

Magazine article Clinical Psychiatry News

Factors for Acute Suicide Risk Are Not Widely Recognized. (Overturning Conventional Wisdom)

Article excerpt

SANTA FE, N.M. -- Much of the conventional lore about predicting suicide risk might be wrong, Dr. Jan Fawcett asserted at the annual conference of the American Association of Suicidology

The suicide literature is dominated by retrospective studies, with all their inherent capacity for bias. The few prospective studies tell a very different story about suicide risk factors, said Dr. Fawcett of the University of New Mexico, Albuquerque. He was a principal investigator in one such prospective study, the National Institute of Mental Health Collaborative Program on the Psychobiology of Depression. The results suggest that standard predictors of suicide risk used routinely in clinical practice might not actually predict acute risk. And the data point to several novel factors that are associated with imminent risk.

This naturalistic study has followed 954 psychiatric patients for 24 years. Half had unipolar depression, and one-third had bipolar disorder. Eighty-five percent were inpatients at entry. The study involved standardized ratings of symptom severity using the comprehensive Schedule for Affective Disorders and Schizophrenia (SADS).

There were 13 suicides in the first year of follow-up--8 in the first 6 months alone--and 34 through the first 10 years. Those numbers underscore a key point: The first year after discharge from a psychiatric facility constitutes an extremely high-risk period for suicide. In this study, more than one third of all suicides occurring over a 10-year period happened in the first year.

In comparing patients who committed suicide in year 1 with those who didn't, the investigators discovered that the two groups did not differ in severity of suicidal ideation, prior suicide attempts, suicidal communications by the patient, or degree of hopelessness.

"It stunned me when I saw that," Dr. Fawcett said. "None of the traditional risk factors were working."

When they scrutinized suicides during years 2-10, however, they found these and other standard risk factors were associated with increased rates of suicide. So the traditional predictors of suicide might be more useful in assessing chronic, long-term risk. Not that that's of much practical use.

"If you're a clinician you want to know what's going to happen in the next year. You're not so worried about years 2-10; you'll get to that when it comes," observed the psychiatrist, who co-authored last year's Institute of Medicine report titled, "Reducing Suicide: A National Imperative."

Multivariate analysis of the first-year experience unexpectedly turned up several novel and highly significant predictors of short-term suicide risk, the most powerful of which was severe anxiety and/or agitation. Other predictors included panic at tacks-present in 62% of patients who killed them selves in year 1 and 29% of those who didn't--as well as global insomnia and recent-onset moderate alcohol abuse, which Dr. Fawcett interprets as an attempt at self-medication for psychic anxiety.

High ratings for depressive turmoil on the SADS also were predictive; only 13 of 951 patients met SADS criteria for depressive turmoil, and 4 committed suicide in year 1.

Several subsequent studies have confirmed the importance of severe anxiety as a major predictor of high short-term suicide risk. …

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