WILLIAM W. K. ZUNG, M.D.

Suicide prevention bysuicide detection

Dr. Zung is professor of psychiatry at the Duke University Medical Center andVeterans Administration Hospital, Durham, N.C. Reprint requests to him at the VAHospital. 508 Fulton Street, Durham. NC 27705.

ABSTRACT: Suicide prevention is based on detection followed byintervention. Detection is accomplished by being aware of knownhigh-risk factors when interviewing patients, and keeping these inmind as high indices for potential suicide. These high-risk factorsinclude: history of previous treatment for emotional problems;present depressive disorder, anxiety, or alcoholism; decreasedphysical health with multiple ailments; presence of self-blameand guilt; loss of self-control; and lack of emotional support sys­tems. Intervention includes the use of hospitalization, psycho­tropic drugs, and the doctor-patient relationship.

Suicide is one of the ten leadingcauses ofdeath in the United Statesand is expected to be responsiblefor the death of some 250,000 peo­ple during the 1970s. To preventthe occurrence of a death by sui­cide, we must be able to detect thepotential of such an act. Thus, sui­cide prevention is accomplishedfirst by detection, then by interven­tion. Suicide as a cause of deathoccurs in men and women; in chil­dren, youth, adults, and the elderly;in whites, blacks, American Indi-

ans, and Orientals; in the poor andrich; in the educated and the un­educated. This has made the iden­tification of the person who is aserious suicidal risk eminently dif­ficult. However, as members of thehealth profession, whose goal is topromote living, we need to knowhow we can prevent people fromdying through suicide.

Sociodemographic factorsHow do we go about trying to solvethe problem of developing high in-

dices ofsuspicion? Two approacheshave been used, and each providesus with its own answers. The first isto look at the sociodemographicprofiles of successful suicides. Bythis approach we can see if thereare any specific characteristics ofthis group that are unique and canhelp us to understand the etiology,diagnosis, treatment for, and pre­vention of this act.

The overall suicide rate per100,000 people regardless of age,sex, and race is 12.5. When thesuicide rate in a particular group isconsiderably higher than this, thatparticular group is at a higher risk.A summary of the results of dif­ferent investigators and their workidentifies the following factors asindicating a high suicide risk:• Age, sex, and race: White men 45years old and over are in a high-riskgroup. So are white women be­tween the ages of 45 and 54; andnonwhite men who are 25 to 34 and75 to 84 years 0Id. I •4

• Marital status: People who aresingle, 25 years old and over; mar­ried and 50 years old and over;separated, divorced, or widowed;

MARCH 1979· VOL 20' NO 3 149

or who have had a recent change inmarital status by being separated,divorced, or widowed.2.;• Religion: Protestants, regardlessof denomination.;• Education: College graduatesand above.b.)• Occupation: The unemployed;members of certain professions,such as doctors, dentists, lawyers.b.)• Length on job: Those who haveworked less than six months onpresent job; who have recently losta job; or who have had two jobs inless than two years.b.)

• Residence: People who havelived in the present place for lessthan six months; or who have re­cently moved.x

• Number in household: Peoplewho live alone..l·~• Household change: Those whosehousehold has changed, either byan increase or decrease in numberor a change in membership.• Community: People who live incenter city.4.b.9• Father's and mother's death:People who have lost either parentby suicide.;• Person's age at parent's death:Those who have lost either parentbefore age 13.b

• Recent loss: People who haverecently lost something of value(family, friend, finances, health,home, pet).4.5

If we are to use this informationas an approach to identify a specificindividual for potential death bysuicide. however, the number ofcandidates would be very large.Given that the total population ofthe United States is about215,000,000, how many would beplaced in the high-risk group byvirtue of their age? their sex? race?marital status? religion? occupa­tion? living arrangement? The an­swer would be a very large number.

MARCH 1979 • VOL 20· NO 3

We also need to remember thatalthough certain events have beenidentified as having occurred withsignificantly greater frequency forpeople who have completed sui­cide, not everyone who fits the de­scription listed above dies by sui­cide. Conversely, if we do use thesecriteria to help us identify high-riskindividuals, we should not be lulledinto thinking that a particular per­son is not at high risk because he orshe does not have a high-risk pro­file. Finally, this approach tells uswho commits suicide, but it doesn'ttell us why. From a heuristic pointof view, the identification of thesecharacteristics provides us withclues for further investigationtoward finding out the why of acompleted suicide.

Current emotional statusThe second major avenue of ap­proach to identifying a potentiallyhigh-risk person involves examina­tion of the patient's emotionalstatus on a here-and-now basis.What clinical factors are importantto identify as underlying causes forsuicidal behavior? Several studiesof completed suicides reveal im­portant findings in this regard. Inone study of 134 consecutive suc­cessful suicides,IO·11 94% of the sub­jects were psychiatrically ill. De­pression and chronic alcoholismaccounted for 68% of the totalgroup. A number of studies l2.1.l in­dicate that 15% of depressed pa­tients will kill themselves duringone or another episode of their de­pression. For a specific depressiveepisode, the chance of death bysuicide is one in 12, or 8%.

The majority of these successfulsuicides (68% ofdepressive patientsand 77% of alcoholic patients)communicated their suicidal inten­tions prior to the act by specific

Suicide prevention

statements of intent (suicidethreat), by statements concerningtheir preoccupation with death anddesire to die (suicide rumination),and by unsuccessful suicide at­tempts. The statements were madeto family, friends, job associates,and many others. In the majority ofinstances, the suicidal communica­tions were made within months ofthe completed suicide. Many of thepatients (73% ofdepressive patientsand 40% of alcoholic patients) hadbeen under direct medical and psy­chiatric care for the illness asso­ciated with the suicide, within oneyear of death. Further, 53% of de­pressive patients and 22% of alco­holic patients had been undermedical care within one month ofthe suicide, including examinationin most cases by a psychiatrist.

Criteria for depression: The diag­nosis ofdepression in this study wasbased on responses obtained dur­ing interviews with close friends orrelatives within a week to a fewmonths after the suicide, using thefollowing criteria:• Presence of "medical" symptomssuch as decreased sleep, decreasedappetite, decreased weight, and de­creased energy• Presence of "psychological"symptoms, such as feeling blue, lossof interest, psychomotor retarda­tion, decreased libido, low expec­tancy of recovery from illness, anddelusions of somatic illness, nihil­ism, poverty, and guilt• Disturbances in social behavior,such as diminished recreational ac­tivity and fewer social contacts.

Criteria for alcoholism: Thediagnosis ofchronic alcoholism wasmade using the definition ofKeller l4: A chronic behavioral dis­order manifested by repeateddrinking of alcoholic beverages inexcess of the dietary and social uses

153

Table 1-Zung Depression Scale Items i

Suicide prevention

of the community and to an extentthat interferes with the drinker'shealth or his social or economicfunctioning. In attempting to es­tablish this diagnosis, it is oftenimportant to obtain a history fromthe family as well as from the pa­tient. It is clear from this study thatthe first consideration in attempt­ing to prevent suicide is the clinicalrecognition of depressive disordersand chronic alcoholism.

In short, the most important ofthe sociodemographic variables isthe patient's past medical history. Apatient who has a history of pre­vious treatment for an emotionaldisorder, including alcoholism, atany time, or has been hospitalizedwithin the past six months for anycondition, is at high risk for suicidalbehavior. In addition, past visits tothe emergency room or outpatientclinic for alcoholism, emotionalproblems, or suicidal behaviorshould also alert the physician tothe risk of suicide.

Using a depression scaleThe patient with a depressive dis­order can be effectively identifiedin any physician's office by the rou­tine use of the Self-rating Depres­sion Scale, or SDS.15.17 Using thistool as a screening aid, the busypractitioner can take the emotionalpulse of his patient. Given to thepatient by the receptionist or nurse,the SDS can be completed in just afew minutes. It is then scored withthe aid of a plastic keyed overlay,and an SDS index is immediatelycalculated. From this, you can ob­tain an index of suspicion for thepresence of a depressive disorder,similar to the detection of hyper­tension when a patient's bloodpressure is taken during a routineoffice visit.

The SDS comprises 20 items,

each related to a specific charac­teristic of depression. Together, the20 items comprehensively delineatethe depressive disorders as they arewidely recognized (Table I). Indi­vidual item scores indicate whatspecific sign or symptom the pa­tient is manifesting, while aggre­gate scores of several items delin­eate the area(s) in which the patientis having the most difficulty. Lastly,the SDS index is a total indicationof "How depressed is this patient asmeasured by this scale?" Combin­ing results from a number of stud­ies, the SDS index can be inter­preted as follows: SDS index below50-within normal range, no psy-

chopathology; SDS index of 50 andover-presence of depressive symp­tomatology of clinical significance.If you wish to assess the patient'sclinical status yourself, and still beable to use the morbidity cut-offscores of the SDS, use the inter­viewer-rated version of the SDS,the Depression Status Inventory.18

Measuring anxietyAnxiety disorders can be identifiedand measured by the use of theinterviewer-rated Anxiety StatusInventory, or the patient-ratedSelf-rating Anxiety Scale, or SAS.'9As with the Self-rating DepressionScale, the SAS can be given to the

154 PSYCHOSOMATICS

Table 2-Anxlety Scale Items

tain diseases involving specificorgan systems and often occurringin combination are seen signifi­cantly more often than in nonal­coholics, and are thus helpful in thediagnosis of alcoholism: (I) Respi­ratory system-tuberculosis, upperrespiratory infections, bronchitis;(2) skin-dermatitis, spider angio­mata, skin lesions, skin ulcers; (3)gastrointestinal system-ulcers,gastritis, diabetes mellitus, dyspep­sia, pancreatitis, jaundice, cirrhosis,hepatitis; (4) bone and joints-gout,arthritis, bursitis; (5) personalhabits-habitual smoker.

Our experience from using inter­viewer-ratings and self-ratings si­multaneously points to the fact thatthere are some differences in re­sponses. On first contact with a pa­tient, you might expect a somewhatmore internally consistent, lessself-condemnatory, and less de­spairing picture to emerge from aface-to-face interview than fromthe self-rated questionnaires. Evenwhen the patient does not reportdespair or hopelessness in an inter­view, it might be wise to questionhim in another modality, say by aself-rating scale such as the Self-

patient as a screening aid by thereceptionist or nurse, and the pa­tient can complete it in a few min­utes. It is then scored with the aid ofa plastic keyed overlay, and an SASindex is calculated immediately.The anxiety rating instrumentscover the symptoms listed in Table2. The SAS index combines resultsfrom a number of studies and canbe interpreted as follows: SASindex below 45-within normalrange, no psychopathology; SASindex of 45 and over-presence ofanxiety symptomatology of clinicalsignificance.

Identifying alcoholismThe following questions, asked ofthe patient, have been found to behelpful in clinical settings to estab­lish alcoholism20: (I) Have you everfelt you should cut down on yourdrinking? (2) Have you ever feltbad or guilty about your drinking?(3) Have you ever had a drink firstthing in the morning as an eye­opener? Positive responses to thesequestions give a highly significantcorrelation (r = 0.89) with the clin­ical diagnosis of alcoholism madeby expert teams. In addition, cer-

I. Affective Disturbances

1. Anxiousness, nervousness2. Fear

II. Somatic Disturbances

6. Tremors7. Body aches and pains8. Fatigue9. Restlessness

10. Palpitation11. DiZZiness12. Faintness

MARCH 1979 • VOL 20 • NO 3

3. Panic4. Mental disintegration5. Apprehension

13. Dyspnea14. Paresthesias15. Nausea and vomiting16. Urinary frequency17. Sweating18. Facial flushing19. Insomnia20. Nightmares

I

I

rating Psychiatric Inventory List2l ,

as we found more hopelessness andguilt emerging through self mea­sures. On the self-rating scale, pa­tients admitted more to a picture ofself-condemnation with self-blame,guilt, and punishment-a moremasochistic and negative self-rep­resentation than is given to an in­terviewer. It may be that it is moredifficult to admit such feelings ofshame and guilt in the interviewsituation than to simply committhem to a piece of paper. In addi­tion, we found that on self-reports,subjects more often admitted suf­fering and discomfort, with emo­tional disruption, and the feelingthat there was no one to turn to forsupport. Again, this feeling of an­guished isolation might be moredifficult to report to an interviewerface-to-face than to admit privatelyin response to a questionnaire.

Clinical assessmentThe clinical features that are im­portant to establish in order toidentify a person at high risk forsuicide are:• Presence of a depressive disorder• Presence ofanxiety and agitation• Feelings of decreased physicalwell-being, with documented mul­tiple physical ailments• Presence of drug abuse, includ­ing alcoholism and taking medica­tions such as sleeping pills• Presence of self-blame and guilt• Loss of self-control with fits ofanger and loss of temper• Lack of support system; feelingthat there is no one the patient canturn to, and that there is no onewho is dependent on him.

Intent and lethalityWhen patients admit to suicide po­tential, the intent and the potentiallethality of the behavior need to be

ISS

Suicide prevention

assessed if suicide is to be pre­vented. Assess the intent by askingwhether suicide as a potential is athought, a feeling; whether it hasbeen verbalized and told to some­ohe; whether there is a specificplan, how well formulated it is, howrealistic it is to carry out; andwhether any recent suicide attempthas been made.

You can assess the lethal aspectof suicidal behavior in terms of thepotential risk-rescue ratio. An ex­tremely high risk would be to stepin front of a fast-moving vehicle,while an extremely low risk wouldbe to take ten or 12 aspirin tablets.A suicidal act may have a highrescue factor if a person took anoverdose of pills in the presence ofanother person, and would have alow rescue factor if the same over­dose took place when nobodywould notice it. Thus, there is ahigh lethality potential when ahigh-risk act is committed (jumpingoff a tall building) with a low­rescue potential (at midnight), anda low lethality potential when alow-risk act is committed (wristslashing) with a high-rescue poten­tial (with witnesses).

InterventionSuicide potential, once established,calls for intervention and treat­ment. In response to the cry forhelp you must take immediateaction.

Hospitalization: Consider hospi­talization if the degree of the de­pression is severe, with the patientfeeling extremely agitated, anxious,helpless and hopeless; or delu­sional, incoherent, or incapable offunctioning. In addition, patientswithout external support systems(family, friends, significant others)need short-term hospitalizationuntil additional information can be

158

obtained. The current law requirescommitment of patients who are adanger to themselves or others, andmanagement of this aspect of thepatient's treatment must be under­taken with the cooperation of thepatient or whoever may be respon­sible for the patient. Become famil­iar with the commitment proce­dures of your particular state.

Psychotropic drugs: If hospital­ization is not indicated, then con­sider the appropriate use of drugs.The classes of psychotropic drugsavailable for treatment are: (I) An­tipsychotic drugs (such as thephenothiazines) for agitation, rest­lessness, delusional thinking, ag­gressive and combative behavior;(2) antidepressant drugs (such asthe tricyclics) for the treatment ofthe underlying depressive disorder;and (3) antianxiety drugs (such asthe benzodiazepines) for the treat­ment of anxiousness, nervousness,agitation, panic spells, apprehen­sion, and symptoms associated withacute alcoholic withdrawal. Whenthe acute phase of the treatment isover, develop and follow through along-range plan of action involvingcontinuation of drug therapy, psy­chotherapy, family therapy, milieutherapy, and the involvement ofother support systems.

Physician-patient relationship:The most important factor in sui­cide prevention, detection, and in­tervention is the physician himself.Your initial attitude and approachto the patient sets the tone for whattakes place thereafter. Your choiceof words, gestures, eye contact, andinterview technique all contributetoward establishing rapport andempathy. The basis for a correctdiagnosis and eventual treatment isbuilt on the first encounter, evenbefore the physical examinationbegins. Use your interplay with the

patient to allay his or her appre­hension, anxiety, and long accu­mulation of pent-up feelings. Dur­ing the interview, and while you areforming your diagnostic impres­sions, keep the following crucialquestions in mind:• Do I feel comfortable with thispatient?• Do I like this patient?• Do I respect this patient?• Do I believe this patient?• Does this patient remind me ofsomeone else, and am I basing mydiagnostic impression on thisresemblance?• Is my diagnostic impression ofthis patient based on sound data, oram I inferring and reading betweenthe lines as I choose?

As you assess the suicide poten­tial of your patient, be a good lis­tener; be direct, understanding,knowledgeable, accepting, reassur­ing, patient, firm; and above all, becommitted to being his physician,for you may well be his last link tohis life support system. 0

REFERENCES1. Devries AG: A potential suicide personality

inventory. PsycholRep 18:731-738,19662. Farberow NL, Devries AG: An item differen­

hation analysis of MMPls of suicidal neuro­psyChiatric hospital patients. Psychol Rep20:607-617,1967.

3. Lester D: Attempts to predict suicidal riskusing psychological tests. Psychol Bull 74: 1­17,1970.

4. Wold C: Characteristics of 26,000 suicideprevention center pahents. Bull Suicidology6:24-34, 1970.

5. Dublin 1I: Suicide: A Sociological and Statisti­cal Study. New York, Ronald Press, 1963.

6. Blachly PH. Disher W. Roduner G: Suicide byphysicians. Bull Suicidology 1-18. t 968.

7. Litman RE, Farberow Nl: Assessment of SIli­cide potentiality. Los Angeles Suicide Pre­vention Center (Manuscript), 1963.

8. Levi D. Fales C, Stein M, et al: separahon andattempted suicide. Arch Gen Psychiatry15:158-164,1966.

9. Dean RA, Miskimins W. Cook R, et al: Predic­hon of suicide in a psychiatric hospital J ClinPsyChOI23:296-301,1967.

10. Robins E, Murphy GE, Wilkinson RH, et al:Some clinical considerahons in the preven­hon of suicide based on a study of 134

PSYCHOSOMATICS

successful suicides. Am J Public Health49:888-899.1959

11. Robins E. Gassner S. Kayes J. et al: Thecommunication of suicidal intent: A Sfudy of134 consecutive cases of successful (com­pleted) suicide. Am J Psychiatry 115:724­733.1959.

12. Lundquist G: Prognosis and course in manic·depressive psychoses. A fOllow·up study of319 first admissions Acta Psychiat et Neurot(suppl) 35:1-96.1945.

13. Stenstedt A: A study In manic-depressivepsychosis Clmical, Social. and Genetic In·

ormal P ycbology of tbeAging Processedited b orman E. Zinberg andIrving Kaufman. 2 5 pp. 15, ewYork. Intematl nal Univer itiePres. 1978.

Pbysiological andPsycbological Considerationsin the Management of Strokeby Arnold BroW.I, 3 pp. 10. Sl.Loui , Warren H. Green, 1976.

Family Medicine-Principlesand Applicationedited by Jack H. Medlllie. 372pp, 15.95, Baltimore, William &Wilkin. 197 .

A Psycbiatric Glo aryedited by the Subcommittee of theCommittee on Public Information,156 pp. 3 paperback.Washington, D. ., AmericanPsychiatric A ociation. 1975.

ew Dimen ion inP ychiatry: A World View,vol2edited b Silvano Arieti andGerard Chrzanow ki, 509 pp.$26.95, ew Y rk. J hn Wiley &

ns. 1977.

Pbenomenology andTreatment of Schizopbrenlaedited by William E. Fann, IsmetKaracan, Ale D. P k my, andRobert I. William , 551 pp, 30.Jamaica. .Y.• Spectrum. 197 .

MARCH 1979 ' VOL 20' NO 3

vestigallons 79: 1-111. 195214. Keller M: Alcoholism: Nature and extent of the

problem Ann Am Acad Poti! Soclat Sci315:1-11.1958.

15 lung WWK A self·rating depression scale.Arch Gen Psychiatry 12:63-70. 1965.

16. lung WWK: From art to science: The diag­nosis and treatment of depression. Arch GenPsychiatry 29:328-337. 1973

17. Birtchnell J. Alarcon J: Depression and at­tempted sUicide: A study of 91 cases seen ina casualty department. Sr J Psychiatry118:289-296.1971

New books receivedCritical I ue in P ychiatricDlagno iedited by Robert L. pitzer andDonald F. Klein, 343 pp. 25

ew York, Raven Pres. 197

Brain Disorders: ClinicalDiagnosi and Management.vol I, no I of Tbe P ycbiatricOinie of ortb America196 pp. 27 per vol, Philadelphia.W.B. aunders. 1978.

Stress and Anxiety, vol 3edited b Irwin G. ara nandCharles D. Spielberger, 360 pp,$18.95, New York, Hal teadPre . 1976.

Tbe Tberapeutic SeJfby John G. Watkins. 543 pp,$19.95. ew York, HumanSciences Press, 1978.

Society, Stre and Disease,vol 3, The Productive andReproductive Ageedited by Lennarl Levi. 295 pp.$41. New York. Oxford UniversityPress, 1978.

Handbook ofP ycbopbarmacology, vol 8,Drugs, eurotransmillers,and Behaviorediled b Le lie L. Iversen. SusanD_ Iversen. and Sol mon H.

n der. 590 pp. 39.50, ew York,Plenum Pres. 1977.

18 lung WWK: The Depression Status Inven­tory: An adJunct to the self-rating depreSSionscale. J Ctin PsychoI28:539-543. 1972

19 lung WWK: A rating instrument for anxietydisorders. Psychosomatics 12371-379.1971.

20. Ewing J. Rouse B: IdentifYing the hiddenalcoholic. Read before the 29th InternationalCongress on Alcoholism and Drug Depen·dence. Sydney. Australia. Feb 3. 1970.

21 lung WWK: The Self-rating Psychiatric In­ventory List. to be published.

interpreting PsycbologicalT t Data, vol I, T tRespon Antecedentb J seph ilbert. 251 pp, 15.95.

ew York, an 0 trandRheinh Id. 197 .

eurology for tbe HouOfficer, ed 2b Howard L. Weiner andLawrence P. Levitt, 180 pp, 9.95paperba k, Baltimore. William'Wilkins. 1978.

P ychotberap in ChronicIcerative Coliti

by Aaron Karush. George E.Daniels. harle FI d, and JohnF. O' nnor. 14 pp. 13.75.Philadelphia. W.B. aunders.1977.

Working Witb Patient :Introductory Guideline forP ychotherapi tby Helen A. De R i. 194 pp,

10.50, cw York. galhonPre . 1977.

Crisi Intervention asP ychotherapyb Charle P. Ewing. 130 pp. 7.95doth. 3.50 paperback. ew York,Oxford niversity Pres, 1978.

bild P cbiatry: ModemApproachesedited b Mi hael Rutter andLionel Herso . 1024 pp. 62.50.Oxford. England. Bla kwcll. 1977.

159