Passive Suicide Ideation: Clinician Beware. Robert I. Simon, M.D.*

Transcription

1 Passive Suicide Ideation: Clinician Beware Robert I. Simon, M.D.* *Clinical Professor of Psychiatry Director, Program in Psychiatry and Law Georgetown University School of Medicine Washington, DC copyright Robert I. Simon,

2 Passive Suicide Ideation: Clinician Beware Robert I. Simon, M.D. No evidence-based research supports the commonly held belief that passive suicidal ideation is less of a risk for suicide than active suicidal ideation. A search of Medline, Cochrane Reviews and MDConsult, using the term passive suicide ideation, found only one article on this topic (see below) but did find a number of articles that included passive suicide ideation in the substance of the article. Passive suicide ideation appears countless times in psychiatric records, articles, texts, guidelines and clinical discourse. It is steeped in the lore and tradition of psychiatric practice. Suicide ideation as discussed here refers to thoughts about dying, either selfinflicted or death by external factors. Although the method of suicide may be active or passive (e.g. firearm suicide vs. suicide by cop), the goal is the same, terminating ones life. The assumption that passive suicide ideation is a subset of suicide ideation that is less severe, reflecting a low risk for suicide, is a falsely reassuring belief. Suicide ideation, such as the wish to die during sleep, to be killed by a vehicle, or to develop terminal cancer, may seem innocuous, but can be a deadly as thoughts of hanging. Presumably, a passive method of attempting suicide allows time for intervention, but methods can change without notice (1). Suicide ideation, without regard to active or passive is a moving target along the continuum of severity, reflecting constant change in the patient s underlying mental disorder and other risk factors (2). copyright Robert I. Simon,

3 Suicidal ideation that expresses active or passive methods of suicide reflect psychodynamic, cultural, religious, moral values as well as patient evasiveness, guardedness, denial and other factors. Passive suicide ideation may contain potential protective factors that are best evaluated separately within the overall suicide risk assessment. Otherwise, the clinician may prematurely conclude that no further risk assessment is necessary. "Fleeting" suicide ideation, a frequent companion of "passive" suicide ideation, also requires careful investigation and evaluation. Hall et al (3), in a study of 100 patients who made severe suicide attempts, found that 29 of the patient's had serious, persistent suicidal ideation before they attempted suicide. However, 69 patients reported only fleeting or no suicidal ideation before their attempt. Reynolds et al (4) assessed the clinical correlates of active suicidal ideation vs. passive death wishes in elderly patients with recurrent major depression. Their data challenged the utility of distinguishing active and passive suicidal ideation, also noting that the patient s ideation can change from passive to active during an episode of illness. They recommend that clinicians be no less vigilant with patients expressing passive suicidal ideation. The Scale for Suicide Ideation (SSI) and the later version, Beck Scale for Suicide Ideation (BSS) (5) rate passive suicidal attempt as: 0. would take precautions to save life 1. would leave life/death to chance (e.g., carelessly crossing a busy street) copyright Robert I. Simon,

4 2. would avoid steps necessary to save or maintain life (e.g., diabetic ceasing to take insulin) Though the Beck scales have psychometric properties (reliability and validity); no scale or portion thereof, can substitute for thorough assessment of suicidal ideation. If used, ratings scales or checklists of suicide ideation should alert the clinician to thoroughly assess the nature and severity of this crucial symptom of suicide risk. CASE EXAMPLE: A 56-year-old business executive is brought to an emergency room by his wife. The patient s business is facing bankruptcy. He is unable to go to the office and face his employees. The patient cannot sleep or eat. Most of the day is spent laying on the couch and crying. The patient s wife threatens her husband with separation if he does not seek psychiatric treatment. The patient tells the emergency room psychiatrist that I am stressed but have no intention of hurting myself. I love my wife and kids too much to put them through that. The patient does admit to having wishes to die in his sleep but says, I can t sleep anyway. The patient s wife found a loaded gun in the glove compartment of his car. The patient states that the gun is for my protection. He angrily denies any suicidal ideation, I do not need to be here. The patient s wife insists that he be treated, stating I will not take my husband home in his condition. The patient refuses psychiatric hospitalization but changes his mind when confronted with involuntary hospitalization. The patient admits that, unknown to his wife, he recently purchased a 2 million dollar life insurance policy and made funeral copyright Robert I. Simon,

5 arrangements. He planned to kill himself with his revolver. A thorough suicide risk assessment reveals a number of risk factors that place the patient at acute, high risk for suicide. CONCLUSION Passive suicide ideation does not inform suicide risk assessment, it merely casts a spell of complacency upon the clinician. It is not a valid clinical distinction. Clinicians do not think of active or passive anxiety, depression or insomnia. Similarly, suicide ideation should not be split into active and passive. To do so undermines the singular importance of suicide ideation as a unitary risk factor for suicide. For too long, the myth has existed in clinical practice that passive suicide ideation is benign, thus creating a false sense that the patient is at little or no risk for suicide. Thus, suicide risk assessment may be prematurely suspended. Suicide ideation must be carefully assessed, not labeled. Passive suicide ideation must not deter the clinician from performing competent suicide risk assessments. Suicide ideation that contains passive or active methods of attempting suicide is a unitary concept that expresses one goal the termination of life. REFERENCES 1. Simon RI: Suicide Risk: Assessing the Unpredictable in Textbook of Suicide Assessment and Management (Simon RI, Hales RE, eds). American Psychiatric Publishing, Arlington, Virginia, 2006 copyright Robert I. Simon,

6 2. Isometsa ET, Lonnqvist JK: Suicide attempts preceding completed suicide. British Journal Psychiatry 173:531:535, Hall RCW, Platt DE, Hall RCW: Suicide Risk Assessment: A review of risk factors for suicide in 100 patients who made severe suicide attempts. Psychosomatics 40: 18-27, Reynolds CF, Frank E, Sack J et al.: Suicide in elderly depressed patients Is active vs. passive suicidal ideation a clinically valid distinction? American Journal Geriatric Psychiatry 4: , Rush JA, First MB, Blacker D: Handbook of Psychiatric Measures. Second Edition. American Psychiatric Publishing, Arlington, Virginia, 2008, pp copyright Robert I. Simon,