July, 2013. The problem of suicide is a relentless and domineering presence in our society and in our field. Media reports regularly cite the latest statistics, and they are almost always alarming, with special focus on populations at increased risk such as active duty military and post-combat veterans with PTSD and other con- ditions. We are also reminded of the elevated risk in the young (particularly adolescents) and in the elderly (particularly men). We learn of a recent shift noted in the demographics of suicide, with increasing rates among aging “baby boomers” reaching late mid-life. Far too many of the individuals comprising these statis- tics were not identified as at risk, or if they were, they were not engaged in treatment. But many of them were in treatment yet unable to surmount the despair and hopelessness and the belief that suicide was their only solution. What we do not know but must never forget, however, is the large number of lives that have been saved by treatment, when patients, with help, find within themselves the resources to move forward and to regain hope and a future.
Representing the American Psychiatric Association and the Physicians Consortium for Performance Improvement (PCPI) of the American Medical Association, I recently participated in a webinar held by the National Quality Forum (NQF), to consider approving a Performance Measure submitted to NQF by PCPI, to establish as a standard the evaluation of a patient with first onset major depressive disorder for suicide risk. Elemental as this standard may seem, it is not carried out with certainty in all clinical settings. Fortunately, the measure was approved and will be endorsed by NQF for use in federal programs and other settings. The measure did not, however, specify a method to use to evaluate suicide risk. While many risk factors for suicide are well known in population-based clinical studies, such as family history, prior attempt, and others, there is no airtight method to establish level of risk in an individual patient, yet that is precisely what clinicians must attempt to do, in collaboration with their patients. In this issue of the Journal, in the Law and Psychiatry col- umn, Wortzel and colleagues thoughtfully discuss risk assessment but also “therapeutic risk management,” as a guide to clinicians to engage in a partnership with their patients to face suicide risk directly and to develop an effective safety plan.
In May 2012, this Journal published an opinion piece by Sadock entitled “Inevitable Suicide: A New Paradigm in Psychiatry,” referring to the ultimate inability of psychiatric treatment to confer absolute immu- nity to suicide. That article stimulated a spirited dialogue, published in the September 2012 issue of this Journal, centering around concern that the term “inevitable” could potentially influence clinicians to abandon hope when treating patients with the most extreme and severe suicide risk. Maintaining hope in such situa- tions can be extremely challenging, and this clinical imperative is the subject of an interesting guest psy- chotherapy column by Dembo published in this issue of the Journal and discussed by Clemens. In all of these considerations, the “reality” of suicide cannot be denied, and our mandate as clinicians is to do our best never to lose hope. Our patients deserve no less.
John Oldham, MD