A recent meta-analysis of suicide risk research conducted over the past fifty years found that less than 1 percent of all studies examined the prediction of suicidal behavior within the next 30 days. Almost all the studies had as their outcome variable whether or not suicidal behavior occurred within the next 12 to 24 months. In large part this explains why suicide research has yielded such a cumbersome wealth of suicide risk factors, including gender (male), race (White), marital status (divorced, separated, or never married), unemployment, substance use (increases impulsivity), physical illness, access to firearms, presence of a mental illness (especially, schizophrenia, bipolar disorder, and major depression), religion (Roman Catholicism and Islam are protective against suicide), even body mass index (lower, perhaps surprisingly) and altitude of residence (higher altitudes = higher risk), etc.
However, mental health clinicians are not asked to predict which of their patients will attempt suicide within the next 24 months; they are expected (by society, courts, and families) to be able to assess a patient’s imminent risk of engaging in suicidal behavior. Imminence is a fuzzy term that often seems to be interpreted in the courtroom as meaning “over the next 48 to 72 hours.” In other words, the good news for clinicians is that no one seriously expects you to be able to see far into the future with unerring accuracy. They are expected, however, to be able to judge the relative risk of suicide and to take appropriate steps to ensure patient safety during a suicidal crisis.
In the absence of solid research into risk factors for imminent suicidal behavior, we have to rely on expert opinion and “clinical wisdom.” These factors have been repeatedly identified: 1) Agitation; 2) Insomnia; 3) Nightmares; and, 4) Social Withdrawal. These observations demonstrate an interesting correspondence to Dr. Alex Caldwell’s speculation about the prototypical MMPI-2 Codetype of a suicide attempter. (that is, what would the MMPI-2 profile of an attempter look like if we could have administered the test shortly before the attempt). Dr. Caldwell imagined that we would most like observe what is called a 2-7-8 Codetype, which he labels as “Internalized Condemnation.” Elevations of Scale 2 represent hopelessness, the conviction that nothing will ever get better. Scale 7 represents agitation, the inability to relax combined with a restless urge to “do something” about one’s predicament. Scale 8 represents mental confusion and self-loathing—the suicidal person concludes that he is the source of his troubles, and that others would be better off without him around.
The identification of "agitation" as a clinical warning sign for imminent suicide is not consistent with many people's view of the depressed and hopeless person. It is always worth remembering that suicide is a violent act and that one of the warning signs of impending violence is agitation. A recent and intriguing “big data” study examined the complete medical records of veterans who died by suicide. Words that were more likely to be found in the medical records of the suicide attempters than in the records of their non-suicidal peers were: 1) agitated; 2) tense; 3) aggravated; 4) delusional; and 5) frightened.
Insomnia is an unsurprising addition to this list because we all know that if you are having problems of any kind, sleeplessness can be sure to make them 10 times worse. But it is useful to think of insomnia as a risk factor for imminent suicide and not just as a common psychiatric symptom. There is a hazard of falling into the "me too" fallacy with regard to a common symptom such as insomnia. A clinician might think, "Well, I don't sleep so well either, but I'm not going to kill myself over it" and thereby misapprehend a patient's true suicide risk.
Nightmares are a curious addition to the warning signs and it is only recently that researchers "rediscovered" this important sign. The reason that nightmares fell out of sight probably has something to do with the fact that in contemporary psychotherapy, psychodynamic dream analysis is frankly unfashionable. Patients used to come to therapy expecting to discuss their dreams, and now they come expecting to leave with some kind of CBT homework assignment. This of course did not mean that patients stopped dreaming (or that their dreams stopped being important sources of data). Another reason that nightmares were not on the radar screen is that the dreams of acutely suicidal people are too terrible to talk about. Unless a caring and empathic clinician asks directly about the nature of these nightmares, the patient will not volunteer them.
Social withdrawal is a particularly troubling sign in adolescents but it is also a warning sign in adults. Social withdrawal can result in sudden weight loss, because a lot of our eating is done communally. (Anhedonia also plays a role in weight loss.) Curiously, there is often reduced alcohol use during a suicidal crisis, perhaps because the alcohol is no longer providing the pleasure or tension relief that it used to. Suicidal people can grow less and less communicative, to the point of mutism. In some ways they might be thinking, "What's the point of talking to people—they wouldn't understand, and they can't do anything to help me anyway."
Thankfully, all of these warning signs are modifiable. Agitation can be alleviated with medication, e.g., low doses of antipsychotic medications such as risperidone. Insomnia can be treated with sleep hygiene psychoeducation and/or medication such as Trazodone (which is both a sleep aid and an antidepressant). Nightmares can be relieved, or at least reduced in intensity and frequency, by describing them in words and sharing them with another person (preferably a clinician). Social withdrawal can be combated by encouraging behavioral activation—get the patient moving again, taking 20 minute walks twice a day, for example. (A recent study in an Swedish hospital found that a hiking program significant helped their suicidal patients.) Eating meals in a group. Encouraging talk in psychotherapy.
More than 90 percent of people who survive a suicidal crisis go on to live normal, healthy lives. Thinking about suicidal is not normal (as I will explain in a future post) and should be taken seriously. Psychotherapy with a competent professional is the best intervention available for suicidal crises. If you or someone else is thinking about suicide—talk to someone about it very soon.