Suicide Screening

Suicidal thoughts are often a symptom of severe major depression. About 2% to 6% of people with this illness eventually commit suicide, and 25% of these suicide attempts are not premeditated. There is no good way to predict in the short term who will attempt suicide, although long-term risk is highly correlated with the following risk factors:

• Hopelessness
• Prior suicide attempts
• Living alone
• Psychotic symptoms
• Significant comorbid anxiety
• Substance abuse
• Male gender
• Caucasian race
• General medical illnesses
• Family history of substance abuse

Suicide risk needs to be assessed in any patient whom you have diagnosed with depression. Specifically, any patients who give a positive response to the suicide item (question 9) on the Patient Health Questionnaire (PHQ-9) should undergo screening to determine their suicide risk. Aetna Depression Management includes some scripted questions, which are based on the Three Component Model, 3CM^TM. These questions are one of the many resources you may wish to draw upon in your professional practice for patients with suicidal thoughts. These screening questions are treatment guidelines and are not a substitution for a physician’s judgment.

For all depressed patients, ask the following questions. In general, this evaluation should take about one minute to complete.

If the patient answers “no” to question 1 and you suspect that the patient’s suicide risk is low, you can likely skip the subsequent questions.

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Always ask patients with depression if they have suicidal thoughts and/or suicidal plans. If they do, find out if they have an active intent (for example, “I’m going to go home and shoot myself.”) or passive intent (for example, “I wish the Lord would take me.”).

If the patient has an active plan to commit suicide and has no self-control or external supports (such as family and friends) for safety, then find a safe way to get the patient to the nearest emergency room.

If the patient does not have an active plan to commit suicide, it is still an urgent situation that could become an emergent one. Here are some guidelines to take for any patient with suicide intention but no active plans:

• Refer for a mental health assessment within 48 hours.
• Share information about whom to contact in a crisis and where to go for emergency help.
• Give immediate treatment, even if a referral for a mental health assessment has taken place, as urgent symptoms may degrade to crisis proportions without it.
• Prescribe medications that are not deadly if overdose occurs (avoid tricyclics and monoamine oxidase inhibitors). If benzodiazepine is prescribed for anxiety while a patient is suicidal, have a family member dispense it, or prescribe it in weekly amounts until the acute risk subsides.

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These guidelines are not intended to be exhaustive, nor are they intended to be prescriptive or replace your own independent medical judgment or your office procedures for addressing suicidal patients.