Reminder from the headlines: Suicide not just about depression

The Washington Post reported yesterday that the Virginia Tech shooter had an anxiety disorder as a child.   I don't want to say much more about that, and I don't know enough about Seung Hui Cho to know whether this did or did not play a role in his actions in April.

But such news can provide a useful reminder to review the prototypes and heuristics clinicians have in our heads about suicide.  Specifically, we need to resist the temptation to only think or ask about suicide in cases of depression.  Although depression is present in a large proportion of  people who die by suicide, suicide is by no means synonymous with depression.   Anxiety disorders, personality disorders, and psychotic disorders are all associated with risk for suicide.  This begins to make sense when you think about suicide often being a response to hopelessness, despair, agitation, and a feeling of being trapped (often with an overlay of substance abuse disinhibiting the person's symptoms and behavior).   When put that way, it's not hard to see how chronic intense anxiety could lead to suicidal thinking (or action).

I think this is something many clinicians know, but old prototypes can be stubborn and often get in the way of us accessing what we know.   When we refresh our thinking, we  can more effectively remember to to ask about suicidal ideation in every case, not just when depression is prominent.

Related posts:
Murder-Suicide, Domestic Violence…Common threads in violence against self and others

Suicide turned outward: Times of London Article by Dewey Cornell

Erratum on previous post: Cornell not author, just interviewed

Thoughts about SAD PERSONS Screen

I've gotten a few questions from colleagues and trainees lately about using the SADPERSONS screen. Most recently, a colleague pointed me to an article in Psychiatric Times titled, "APA: Simple Screen Improves Suicide Risk Assessment." The topic seems worthy of a post to think through both the appeal and risks of the SADPERSONS scale.

For those who are not aware of SAD PERSONS, it is a 10-item scale to purports to screen for suicide risk. An individual is given one point for each item for which he or she screens positive:



  • Sex (male)

  • Age less than 19 or greater than 45 years

  • Depression (patient admits to depression or decreased concentration, sleep, appetite and/or libido

  • Previous suicide attempt or psychiatric care

  • Excessive alcohol or drug use

  • Rational thinking loss: psychosis, organic brain syndrome

  • Separated, divorced, or widowed

  • Organized plan or serious attempt

  • No social support

  • Sickness, chronic disease


The word "simple" in headline of this Psychiatric Times article linked above captures what makes the tool sound appealing, especially for the thousands of health care systems that need a quick way to respond to the JCAHO patient safety goal 15 and 15A: "The organization identifies safety risk inherent in its client populations" and "The organization identifies clients at risk for suicide" (see this .pdf for explication of these goals).

From one perspective, there is nothing wrong with using acronym like this. It can remind clinicians (assuming they can remember what all the letters stand for!) of some of the risk factors and warning signs of suicide. Who can argue with that? However, from a training and clinical perspective, there are a few problems with this approach, especially when the screen is put forward as a scored scale. Let me summarize a few of these. Note that my thinking about some of these concerns is strongly influenced by concerns articulated by my senior (and very brilliant) colleagues in email exchanges we have had about this. I don't claim originality here, just summary:

  1. The "scale" assigns risk level on the basis of a point system: A score of 1 or 2 points indicates low risk, 3-5 points indicates moderate risk, and 7-10 indicates high risk. This approach works under the assumption that these factors are equally weighted. A separated, 46-year old male with diabetes with no depression would have a higher risk level (score=4, moderate), than 40 year-old married woman with chronic depression, current hopelessness who was just released from a psychiatric hospital after a near-hanging. (score=2, low risk).

  2. Having a risk "score" creates conditions for clinicians to rely on a number instead of developing an informed clinical formulation of risk.

  3. The suggestion that risk for suicide can be boiled down to a single number--even for screening purposes--presents a misleading picture of the complexity phenomenon and how to think about it as a clinician.

  4. The evidence that the linked article gathered does not correspond with the alluring headline, "Simple Screen Improves Suicide Risk Assessment." Evidence reported by those who conducted the study was that, after using the computerized screen, nurses tested showed more knowledge about risk factors for suicide. Of course, knowledge about factors is a long way from demonstrating improved assessment. Obviously, the physicians who reported their study at APA the study did not write the headline. The semantic overreach of the headline speaks to the understandable desire to find easy ways of doing hard things.

  5. Finally, from a training perspective, I find acronyms longer that 3 letters almost impossible to remember! SAD PERSONS particularly clumsy, and, IMHO a bit forced. "O" stands for "Organized plan or serious attempt" whereas I would probably make plan a "P" if I were trying to remember it, but of course that's already taken by "P" for "Previous." That often ends up being the problem with trying to make these things fit into an acronym. In a way, this gets back to the theme I've been harping on lately in my posts about teaching and training about needing a basic-science base about how clinicians learn, remember, and use principles or practices we learn. I'd imagine an expert in human memory could graph the inverse relationship between recall rate and number of letters in an acronym--add to that the need to recall these letters that signify words or concepts with high emotional impact.

In summary, while SAD PERSONS may be helpful to some people as a tool for remembering risk factors, it has some serious limitations as risk assessment "scale" and probably as a mnemonic.

CTL censored in China

Thanks to a post by Dr. X, I discovered that this blog is banned in China--at least according to the Great Firewall of China, a site that purports to test any URL to see if it is blocked in China.    I'm interested to know how sites make the blacklist.  That there must be a keyword algorithm or something like that for censoring site--if so, I guess "suicide" or "risk" is on that list.

Owner of Chinese Toy Factory Dies - New York Times

Almost nothing is known about this factory owner, so we should be careful about what lessons we draw.  But this news is a sad and startling reminder that job loss and financial pressure (here mixed with public humiliation) raises risk of suicide.
Owner of Chinese Toy Factory Commits Suicide - New York Times.

Murder-Suicide In Ireland

Ireland has experienced a string of murder-suicides of different types over the past 18-months.  The most recent of these events, which occurred Tuesday, prompted this Statement From The Irish Association Of Suicidology, as reported in Medical News Today.  In scanning the Irish Examiner today, I ran across this article advocating for funding psychological autopsies in the country.

Two Large Studies Show Decline In Suicide Attempts With Antidepressant Treatment

Genetic Variations May Predispose Some Men To Suicidal Thoughts During Treatment For Depression

Genetic Variations May Predispose Some Men To Suicidal Thoughts During Treatment For Depression

Researchers at Harvard/Mass General have contributed some interesting data to the conversation about suicidality and antidepressant treatment. Roy Perlis and colleagues examined available DNA info on patients who had new onset suicidal thoughts after starting drug therapy, and found an interaction effect (sex x genetic variation) that suggested that the men with the genetic variation were at greater risk of suicidal thoughts. The article by Roy Perlis and colleagues appeared in the most recent issue of Archives of General Psychiatry. For a lay description of the study see this article in Medical News Today.


Because of the nature of the sample and the narrow scope of the findings, this study contributes most to the understanding about a possible link between suicidality and antidepressant use, about which I have posted before. But my main interest in it here relates to what new findings (especially those with a strong biomedical basis) mean to clinicians and how we think about risk assessment.

If replicated and expanded findings like these might lead to more targeted approaches to suicidality (and probably psychopharmacology for depression). However, for the clinician faced with an at-risk person in treatment, each new discovery will be merely one factor to synthesize into an overall, well-constructed risk formulation. It is doubtful we'll ever get to the point where a single data point (genetic or otherwise) will be strong enough to predict risk by itself. We'll always need good, old fashioned, clear-headed, complexity-embracing clinical judgment to discern risk. In fact, new findings related to risk (especially complex ones like those in the Perlis study) point out the importance of having a sturdy framework for thinking through risk assessment. A systematic framework allows the clinician to incorporate new findings into thinking and practice.

The need for a framework for thinking through risk may seem too obvious to mention. But consider what most training in suicide risk assessment consists of. Nearly every clinician I've spoken to (including myself) learned to assess suicide by asking a few basic questions about suicidal thinking, plan, intent, and ability to agree to stay safe. Most of us were not taught a "framework at all." We did not learn to assess for suicide risk the way we do other clinical issues--via systematic assessment and synthesis of multiple data points. In my opinion, that is why many clinicians I talk to feel so unsatisfied with the experience of working with people who voice suicidality.

All that to say...we're likely to see more genetic links with suicide risk. My goal is to be prepared to assimilate new findings within:

  • a compassionate and autonomy-respecting approach to gathering data (of all kinds) and intervening

  • a systematic way of thinking through multiple risk factors to arrive at a formulation

  • a coherent and predictable format for documenting and responding to risk

FDA ammends recommendation for antidepressant blackbox warning

In a previous post, I reflected on unintended consequencesof the FDA blackbox warning on antidepressants.   The FDA has proposed modification of the warning that (a) extends the age range of the warning to 24 and (b) includes explicit recognition that there is no data indicating danger for other ages, and that untreated depression presents its own risk.   The American Psychiatric Association has issued this press release(note: .pdf file)  applauding this second part of the new FDA proposal.

Erratum on previous post: Cornell not author, just interviewed

Correction on my previous post about the Times London article about suicide turned outward.  Although the website makes it look like Dewey Cornell wrote the article I cited, Dewey has informed me that he did not author the article, but was interviewed by a reporter who wrote it.   I guess they do by-lines differently on the other side of Atlantic...

Suicide turned outward: Times of London Article by Dewey Cornell

In a previous post, I shared some raw thoughts about some of the connections between suicide and violence. Here is a thoughtful and thought-provoking piece by Dewey Cornell (a former teacher of mine at UVA) that brilliantly captures those connections and others. Strongly recommended psychological and social commentary about the VA Tech murder-suicide last week.

Sad news in Rochester

A vice-principal of a local school died by suicide this week.  He had gone missing last Friday and was found earlier today (read the story in the Democrat and Chronicle).  It is always shocking and confusing for survivors, but this is especially true when a more public figure dies.  Students at the high school and the whole community is in shock.  Suicide, even when there are warning signs is ultimately unpredictable.

I was interviewed by R-News today about what to tell survivors--in terms of understanding the death and in terms of resources.  The reporter said that many journalists are struggling with how to report the story in the most helpful way for the community and the family, because suicide deaths often do not get the extensive coverage that this story demands (since Mr. Thurston's disappearance was so public and his discovery so dramatic).

I'm sad about this death, and pleased about how the school, the community, and the news media have been handling the matter.

Murder-Suicide, Domestic Violence...Common threads in violence against self and others

The murder-suicide that took place at Virginia Tech on Monday on a lot of people's minds right now.  Certainly on mine.  So sad.

This event was mentioned several times at a conference I attended parts of today on "Multidisciplinary perspectives on partner violence".   In fact, one of the key speakers, Sandra M. Stith, Ph.D., is a faculty person at Virginia Tech.  She gave a marvelous talk about work she and her colleagues are doing with high conflict couples in multicouple groups.   Before speaking, she made poignant comments about her decision to speak at the conference instead of heading home.   It was clear from listening to her speak that she deeply understood the close connection between prevention of different forms of violence.

Which bring us straight to the topic of suicide.   Catherine Cerulli, a faculty member in our department and one of the conference organizers, gave a powerful presentation titled, "Domestic Violence as a risk factor for suicide and murder-suicide."   As I listened to this talk and to others today, the connection between violence and suicide was unmistakable.  The take home message for assessment is this:  we need to think about violence when we hear suicide, and suicide when we hear about violence.  History of trauma or DV are not just statistical risk factors.   They are intertwined and interrelated in substantive and clinically meaningful ways.  Cate played a horrific tape of a 911 call that illustrated this in a visceral way.  A woman with a past history of suicide attempts, ends up involved in the death of her violent male partner--which occurs during the 911 call.  (It is not clear if she actively stabbed him or just held the knife and he impaled himself).   The relationship between different kinds of risk (violence against partner and violence against self) is so complicated as to be practically indistinguishable.

So...a few free associated questions related to clinical assessment:

When we see a depressed youth with suicidal risk, are we asking enough about violence in the home (past or present, witnessed or experienced)?
When we see DV, how thorough are we about suicide assessment?
When we see suicidal individuals (especially men) who have some antisocial features are we thinking about their potential for violence against others, including (especially) against intimate others?
Are we remembering that involvement with the criminal justice system puts people at greater risk for suicide?

Murder-suicide like the one the country has experienced this week is not a statistical coincidence--it teaches us something about the heart and processes behind both.