A 37-year-old woman with a history of recurrent major depressive disorder comes to the office. Her father died last month after a long illness, and she is concerned that her depression is returning. The patient has little appetite, sleeps poorly, and has difficulty concentrating at her job as a teacher. She recently stopped going to the gym and socializing with friends, activities that she used to enjoy. She has been collecting pills from half-empty bottles of old medication and has considered taking all of them at once. The patient has no history of suicide attempts. Her mother completed suicide at age 40. Which of the following is the most important factor in assessing this patient's suicide risk?
Suicide risk assessment: evaluate ideation, method, plan, intent | |
Suicidal |
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Method/ |
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Preparations/ |
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Intent |
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Assessment of suicide risk requires detailed questioning to determine the presence of suicidal thoughts and plans. Suicidal thoughts can be differentiated as passive (wish to be dead or not wake up) versus active suicidal ideation (actual thoughts of killing oneself). Patients who have active suicidal ideation should be further questioned about whether they have thought about specific methods of killing themselves and whether they have made any preparations and plans for suicide. Finally, the strength of the patient's intention to carry out the suicide plan should be assessed.
Although this patient has several risk factors, it is her recent preparation for suicide (ie, collecting old medication with a plan of taking an overdose) that is the most concerning. Patients with active suicidal ideation and intent who have made preparations to carry out a specific method of suicide are at highest risk. Hospitalization may be necessary to ensure their safety.
(Choices A and F) This patient's other risk factors for suicide include her family history of suicide (considered a static risk factor) and recurrent episodes of major depressive disorder. They are not as important as her recent active suicidal ideation associated with a specific method and preparatory behavior.
(Choices B and C) Social isolation and insomnia are common symptoms of major depression that occur in patients with and without suicidality. Although they increase the risk for suicide, they are not as critical as this patient's active suicidal ideation and preparations.
(Choice E) Although suicide risk increases in patients who have lost a loved one, this is not as strong a risk factor as having active suicidal ideation with a plan.
Educational objective:
Patients with suicidal thoughts should be assessed for intent and plan. Patients with active suicidal ideation and intent who have made preparations to carry out a specific method of suicide are at highest risk.