Suicide Risk

Background

Transient suicidal thoughts are common for some people throughout the course of HIV disease and often do not indicate significant risk of suicide. However, persistent suicidal thoughts with associated feelings of hopelessness and intent to die are very serious and must be assessed promptly and carefully. Compared with people at high risk of suicide who are not HIV infected, people living with HIV have significantly increased frequency and severity of both suicidal ideation and thoughts of death. The risk of suicide is especially high for patients who are depressed and for those at pivotal points in the course of HIV infection. Stigma, quality of life concerns, and issues regarding disclosure may be contributing factors.

Suicidality may be the direct physiological result of HIV (e.g., owing to the impact of HIV in the brain), a reaction to chronic pain, or an emotional reaction to having a chronic and life-threatening illness (e.g., major depression as a result of physical illness or psychiatric side effects caused by medications used to treat HIV infection and associated comorbidities). Many events may trigger suicidal thoughts among people with HIV. Such events include learning of their positive HIV status, disclosing to family and friends, starting antiretroviral therapy (ART), noticing the first symptoms of infection, having a decrease in CD4 cell count, undergoing a major illness or hospitalization, receiving an AIDS diagnosis, losing a job, experiencing major changes in lifestyle, requiring evaluation for dementia, and losing a significant relationship.

Evaluation of suicide risk must be included as part of a comprehensive mental health evaluation for HIV-infected patients. Note that asking patients about suicidal thoughts does not increase their risk of suicide.

Risk factors for suicide attempts include the following:

  • Previous suicide attempts
  • Abandonment by or isolation from, family, friends, or significant others
  • Age >45 for men, >55 for women; or teen years
  • Male gender
  • Gay sexual orientation
  • Transgender
  • Any acute change in health status; worsening of HIV-related illness or other physical illnesses
  • Family history of completed suicide
  • Alcohol and other substance misuse, abuse, or dependence
  • Relapse into drug use after significant recovery
  • Severe anxiety, depression, psychotic disorder, or other mental health disorder
  • Domestic violence
  • Social isolation (e.g., being single, divorced, or alone, or experiencing the death of a spouse)
  • Multiple losses or recent stressors
  • Financial difficulty, unemployment
  • Hopelessness and lack of pleasure
  • Impulsivity
  • Pain
  • Perception of poor prognosis
  • Perception of poor social support
  • Planning for death
  • Stigmatization associated with illness, sexual orientation, substance use history, or other factors
  • Fear of HIV-associated dementia

Protective factors include the following:

  • Strong psychosocial support
  • Evidence of good coping mechanisms
  • Cultural and religious beliefs against suicide
  • Reasons for living
  • No specific plan for suicide

S: Subjective

The patient expresses or exhibits, or a personal care giver discloses, the following:

  • Active suicidal ideation with intent and plan, such as giving away significant personal belongings, saying goodbye, acquiring the means (e.g., gun, pills), writing a suicide note
  • Depressed mood, hopelessness, agitation, intoxication with alcohol or other drugs
  • Passive withdrawal from therapy or medical care or decreased adherence (e.g., stopping medications, missing appointments)
  • A desire for HIV disease to progress more rapidly

Inquire about the following during the history (again, note that asking patients about suicidal thoughts does not increase their risk of suicide ):

  • Previous suicide attempt(s) - one of the best predictors of eventual death by suicide
  • Friend or family member who has committed suicide
  • Personal or family history of depression
  • Previous episode of psychosis
  • Presence of risk factors described above

Probe for other depressive symptoms and the immediacy of potential suicidal intent. Sample questions may include the following:

  • "It sounds as if you're in great pain. Have you ever thought that life is not worth living?"
  • "Do you often think of death?"
  • "Do you think about hurting yourself?"
  • "How might you do that?"
  • "Do you have a plan?" Ask whether the patient has access to the components of the plan (e.g., gun, pills)
  • "Is this something you feel you might do?"
  • "What would prevent you from doing this?"
  • "Have you ever attempted suicide? What did you do?"

O: Objective

  • Perform a mental status examination and suicide assessment.
  • Look for signs of self-inflicted injuries such as wrist lacerations or neck burns.
  • Look for signs of depression, agitation, or intoxication.

A: Assessment

See chapter Major Depression and Other Depressive Disorders for differential diagnosis of possible causes of depression and suicidality.

P: Plan

Evaluation

Evaluate the patient for depression, risk factors for suicide, and contributing psychiatric illnesses or situational stressors. Determine the immediacy of potential suicidal intent. If a mental health professional is available on site or can be summoned, an urgent consultation often is helpful in making these determinations.

Treatment

  • If the patient exhibits active suicidal ideation with a plan, hospitalize the patient immediately, preferably in a psychiatric facility.
  • If suicidal thoughts are passive, refer for evaluation for specific psychiatric disorders and refer for psychotherapy with an HIV-experienced mental health provider.
  • Encourage the patient to contact you or another specified clinician for help, or to go to a hospital if suicidal ideation worsens or patient worries about acting upon suicidal thoughts.
  • Note that making a contract with a patient against suicide is not recommended; research shows it is not effective, and it can provide a false sense of security.
  • Inform patients about local suicide prevention resources, including suicide hotlines, emergency response (e.g., 911), and local emergency departments.
  • Contact the patient between appointments. Enlist the help of significant others (if the patient agrees); invite them to accompany the patient on the next visit and see all of them together. Consider a support group or peer referral, if available.
  • Consider dispensing medications on a weekly basis for the following purposes:
    • Monitoring emotional status and treatment adherence
    • Preventing the availability of lethal doses of medications
  • Perform appropriate follow-up. In consultation with a skilled mental health provider, be sure that the patient is receiving appropriate ongoing treatment for underlying or persisting psychiatric illness. Assess at each visit for adherence to mental health care and for recurrence of symptoms.

Patient Education

  • Suicidal ideation and severe depression are not normal aspects of HIV infection, and usually can be treated effectively.
  • Patients should report suicidal thoughts to their health care provider.
  • Inform patients about local suicide prevention resources, including suicide hotlines, emergency response (e.g., 911), and local emergency departments.

References

  • Cournos F, Lowenthal D, Cabaniss D. Clinical Evaluation and Treatment Planning: A Multimodal Approach. In: Tasman A, Kay J, Lieberman JA, et al., eds. Psychiatry, Third Edition. Hoboken, NJ: John Wiley & Sons; 2008;525-45.
  • Gielen AC, McDonnell KA, O'Campo PJ, et al. Suicide risk and mental health indicators: Do they differ by abuse and HIV status? Women's Health Issues. 2005 Mar-Apr;15(2):89-95.
  • Goldstein RB, Black DW, Nasrallah A., et al. The prediction of suicide: Sensitivity, specificity and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders. Arch Gen Psychiatry. 1991 May;48(5):418-22.
  • Kelly B, Raphael B, Judd F, et al. Suicidal ideation, suicide attempts, and HIV infection. Psychosomatics. 1998 Sep-Oct;39(5):405-15.
  • Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in national comorbidity survey. Arch Gen Psychiatry. 1999 Jul;56(7):617-26.
  • Komiti A, Judd F, Grech P, et al. Suicidal behaviour in people with HIV/AIDS: a review. Aust N Z J Psychiatry. 2001 35(6):747-57.
  • Mountain Plains AIDS Education and Training Center. HIV and Suicide: Risk Assessment and Intervention. 2007.
  • New York State Department of Health AIDS Institute. Mental Health Care for People with HIV Infection: Clinical Guidelines for the Primary Care Practitioner. Accessed December 1, 2013.
  • Robertson K, Parsons TD, Van Der Horst C, et al. Thoughts of death and suicidal ideation in nonpsychiatric human immunodeficiency virus seropositive individuals. Death Stud. 2006 Jun;30(5):455-69.
  • Roy A. Characteristics of HIV patients who attempt suicide. Acta Psychiatr Scand. 2003 Jan;107(1):41-4.
  • Wainberg ML. Mental Health Issues in HIV-Positive Patients. Presentation at the 3rd annual Mountain-Plains AIDS Education and Training Center Faculty Development Conference, Keystone, CO. Mountain Plains AIDS Education and Training Center; 2005.