Doctors worry they might kill their patients. Therapists have to worry their clients will kill themselves. Lethality assessment shouldn’t be a nerve-wracking process of guesswork and intuition, but clients can’t always think clearly enough in crisis to give us straightforward answers. Three recent studies identify newly-substantiated risk factors for us to consider.
Trauma and suicide are clearly linked. In a 2009 article [i] for the Journal of Traumatic Stress, Jakupcak, Cook, et al found that veterans who meet criteria for post-traumatic stress disorder are four times more likely to consider suicide than those who don’t. Researchers at the University of Manitoba [ii] have identified key post-traumatic symptoms that indicate higher risk. After talking to 2,322 subjects and controlling for other mental health issues, they found that physical reactions to reminders of the trauma, being unable to recall some part of the trauma, and having a sense of foreshortened future were all strongly associated with suicide attempts. If you felt wrenched with every reminder of something you couldn’t remember properly, how long could you tolerate a persistent sense of doom?
Client’s families can also give clues to the risk of suicide. Anju Mathew and Anil Prabhakaran of the Government Medical College, Thiruvanathapuram, Kerala, India, tracked “expressed emotion,” a measure of how much criticism, hostility, or emotional over-involvement family members show. Per their findings [iii], the more clients felt criticized after a suicide attempt, the more likely they were to try it again. We wish all of our clients returned from the hospital to supportive, understanding families. Unfortunately, it’s too rare that people with such serious issues have families that respond in a caring, validating way. Prabhakaran and Mathew suggest therapists involve the family members in sessions after a suicide attempt. They suggest families will be less critical if they have the chance to work through their thoughts and feelings, and better understand their loved one’s needs. At the very least, we should ask such clients, “How did your family take this?”
If you’ve ever told clients, “Everyone thinks about suicide now and then,” stop. A 1999 review of nine western countries [iv] found the highest percentage that had considered suicide at some point during their lives was only 18.51%. (This was in New Zealand – apparently a hobbit-ridden archipelago of despair.) Ideation is highly correlated with attempts. Simon, Rutter, et al [v] reviewed Patient Health Questionnaire (PHQ-9) Depression Screens completed between 2007 and 2011 by 84,418 primary-care patients; 704 of whom would attempt suicide and forty-six of whom would die from it. The PHQ-9 asks, “Over the past two weeks, how often have you been bothered by the following problems?” Those who reported, “Thoughts that you would be better off dead, or of hurting yourself,” had bothered them nearly every day were ten times more likely to attempt suicide over the next year than those who answered, “Not at all.” They were ten times more likely to succeed. If the actual percentages are relatively small, (from 0.4% to 4% for an attempt, and 0.03% to 0.3% for successful suicide), the factor of ten makes it worth our time to ask how often clients think about ending their lives.
Marsha Linehan’s UWRAP and UWRAMP protocols are helpful checklists to use when assessing suicidal clients. They don’t tell us which clients are more likely to reach a suicidal crisis. These studies give us three more questions to ask when considering how carefully to watch a client: “How did your family respond when you attempted suicide?” “Have you been having physical reactions to reminders something you can’t remember, but left you feeling jinxed?” and, most simply, “How often does suicide cross your mind?”
@ 2014 Jonathan Miller All Rights Reserved
[i] Jakupcak M, Cook J, Imel Z, Fontana A, Rosenheck R, McFall M. Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans. J Trauma Stress. 2009 Aug;22(4):303-6. doi: 10.1002/jts.20423.
[ii] 2. Zeynep M.H. Selamana, Hayley K. Chartrandb, James M. Boltona, Jitender Sareena, Which symptoms of post-traumatic stress disorder are associated with suicide attempts? http://dx.doi.org/10.1016/j.janxdis.2013.12.005
[iii] Mathew A, Prabhakaran, A. Perceived Expressed Emotion as a Risk Factor for Attempted Suicide – A Case Control Study International Journal of Recent Trends in Science and Technology, Volume 9, Issue 2, December 2013 pp 299-302
[iv] Weissman MM, Bland RC, Canino GJ, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Rubio-Stipec M, Wells JE, Wickramaratne PJ, Wittchen HU, Yeh EK. Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, Volume: 29 Issue: 1 Pages: 9-17, DOI: 10.1017/S0033291798007867
[v] Simon GE, Rutter CM, Peterson D, Oliver M, Whiteside U, Operskalski B, Ludman EJ. Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death? Psychiatric Services 2013; doi: 10.1176/appi.ps.201200587
2 responses to “New Warning Signs of Suicide”
An excellent article, and appreciate the helpful new information. PTSD linked to suicidality is perfectly understandable. This gives fresh insight for assessing. Thank you, Jonathan!
Thank you Jonathan, it is very useful information that every therapist needs to know. I would have this in mind when working with clients with PTSD.