Experts Address Puzzle of How to Predict Suicide Risk, Set Future Directions

Little is understood about the factors that predict imminent suicide risk, and mental health professionals hold differing opinions about whether and how suicide risk can be assessed. During an Annual Meeting session today, presenters discussed various perspectives on suicide risk and highlighted new research that may guide the field in assessing and managing risk.

“Understanding who will engage in suicidal behavior—and just as importantly, when a suicide may occur—is essential to improve clinical care,” said Megan Rogers, Ph.D., the session’s chair and a postdoctoral research fellow at Mount Sinai Beth Israel.

Overall, there are numerous limitations associated with assessing and managing risk for suicide, Rogers explained, including an overreliance on suicidal ideation assessments to predict who and when someone will engage in suicidal behavior and uncertainty about what imminent suicide risk really represents.

During the session, Alan Berman, Ph.D., an adjunct professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine, explained the viewpoint held by some within psychiatry that clinicians lack the tools to use anything more than their intuitive judgment to determine a patient’s imminent risk for suicide. Additionally, there is no definition of “imminent” in the suicidology literature, making assessing such risk even more difficult. Berman pointed out how difficult it is to predict the near future, and quoted Robert I. Simon, M.D., who called the concept of imminent suicide risk “an illusory time frame on an unpredictable act.”

Suicide risk assessments require patients to report their suicidal ideation, which is an inherently flawed process, explained Igor Galynker, M.D., Ph.D., associate chair for research in the Department of Psychiatry at Mount Sinai Beth Israel. “We’re relying on patients in the most serious and dangerous times of their lives to tell us clearly what they are thinking and what they plan to do,” he said. “Additionally, 75% of people who die by suicide do not tell anyone about their plans.”

For years, Galynker and his colleagues have been working to solve the puzzle of how to accurately predict suicide risk. They identified a short-lived suicidal mental state theorized to precede imminent suicide risk called the suicide crisis syndrome (SCS), and they have submitted a proposal to include SCS in DSM.

There are five symptom domains of SCS, divided into criteria A and criteria B. “Criteria A is what we call frantic hopelessness, or entrapment. It is the urge to get out of an unbearable life situation, when all other routes of escape are blocked, so that death appears to be the only option,” Galynker said. This is the main symptom of SCS.

Criteria B include four symptoms, including affective disturbance (including emotional pain); loss of cognitive control (including ruminative flooding, or the inability to control thoughts and feelings accompanied by head pain or pressure); insomnia and agitation (most suicides take place at night, Galynker noted); and social withdrawal. SCS is an acute state, similar to a panic attack, he said. It may last from hours to several days.

During his presentation, Galynker shared how SCS can be utilized in the emergency room setting and not only catch those individuals who truly have imminent suicide risk, but also prevent unnecessarily overusing hospital resources for patients who are not at risk. He outlined the numerous benefits of SCS, including that it facilitates decision making for physicians, improves communication, reduces dependence on self-reported suicidal ideation, empowers clinicians to use their clinical judgment, and reaches all patients, rather than just those patients deemed at risk.

He also outlined some of the arguments against SCS, such as that it attempts to overmedicalize suicide. “Our response is that we must medicalize presuicidal state of mind so [patients with] SCS can be treated with medications,” he said.

Kristin Fredriksen, M.D., highlighted the necessity of identifying factors that predict suicide risk during and following inpatient psychiatric treatment. Fredriksen, a psychiatrist with Stavanger University Hospital in Norway, described the findings from a prospective cohort study of 7,000 patients admitted to a psychiatric acute unit in Norway. The study is currently in review for publication.

Fredriksen and colleagues examined predictors of death by suicide (both inpatient and following discharge) within a week of admission. The goal was to determine the relevance of a depression diagnosis, severely depressed mood, suicide attempt, and suicidal ideation for imminent suicide risk.

The authors found that severely depressed mood, including inappropriate self-blame and guilt, was the only significant predictor of suicide during the first week after admission. Further, they discussed that intense affective states among the participants increased the risk of suicide, a finding that was compatible with elements of SCS. Psychotic/psychosis-like ideas of self-blame also increased suicide risk. The findings support other studies hypothesizing that psychotic processes may transform suicidal thoughts into suicidal acts, Fredriksen said. Finally, the authors found that self-reports of suicidal ideation were not a good measure of imminent and short-term risk of suicide for acute admitted inpatients. ■