Transcript: What We Know About Reducing Suicide Risk

Charles Raison, MD, talks with John Mann, MD, about the current state of knowledge on suicide risk factors. To watch a video of their conversation, click here.

DR. RAISON: Good morning, I’m Dr. Charles Raison. I’m on the Steering Committee of the US Psych Congress, and I’m here with Dr. John Mann. Thank you for being with us. I want to talk to you a little about suicide this morning. One of the famous things we say in psychiatry is that we’re terrible at predicting suicide. But we’ve gotten a little better, haven’t we? I think now in recent years, is it the case that we have a better idea of things that suggest that someone is either at increased risk of either killing themselves or trying to kill themselves? 

DR. MANN: Well, what we’ve gotten better at is understanding that the main risk for suicide in the Western world, including the United States, is someone who is suffering from a depressive episode and is untreated. So, if we can raise the bar slightly, which is diagnose more people and treat them effectively, then we’re going to reduce the suicide rate. 

DR. RAISON: And, what percentage of people that kill themselves, do we know what percentage would qualify as having a current major depressive episode? 

DR. MANN: About 90 to 95% of people have a psychiatric diagnosis at the time of death that we think is relevant for their suicide, and about 60% of those have a mood disorder. 

DR. RAISON: A lot of people have depression. Are there things within a mood disorder that somebody could watch for that increase the risk of someone killing themselves or trying to? 

DR. MANN: So, the degree of clinical severity as distinguished by the clinician doesn’t seem to be very good at distinguishing people who are at risk from people who are not at risk. The patient is better at distinguishing themselves. The patients who describe a lot of suicidal thoughts feel very hopeless, see fewer reasons for living, perhaps feel pessimistic, for example, about the possibility of the antidepressants working. Those people are at greater risk. 

DR. RAISON: And I’ve heard, I’ve seen some data suggest, that people who are very anxious or agitated are also at increased risk. Has that held up in terms of being a risk factor? 

DR. MANN: It’s probably a little more complicated. The people who are mild-to-moderately anxious are actually afraid of doing things in general, and that includes making suicide attempts. But the people who have a psychomotor agitation, those people are at greater risk.  

DR. RAISON: So people that are pacing, agitated, if you see that acutely, that’s also a warning sign?

DR. MANN: Yes, one of the classic examples is the male inpatient with psychomotor agitation pacing up and down the unit. Those patients need to be watched very carefully. 

DR. RAISON: Yes, I’ve done inpatient work and I’ve seen a few of those come to a bad end. 

So, depression is very common, but are there other less common psychiatric conditions that are even a greater risk for suicide but just not, just don’t happen as often? 

DR. MANN: That’s a very good question. So, alcoholism is probably as dangerous or more dangerous, and since alcoholism is often comorbid with mood disorder, one really needs to watch those patients very carefully. 

Some conditions like eating disorders—people don’t usually think of eating disorders as a risk factor for suicide. But patients with eating disorders often have mood disorders as well as part of an eating disorder, so they do they do have an elevated suicide risk. 

DR. RAISON: What about people in a mixed state? The combination of depressive and a manic presentation, or people with mania? Even, you know, classic manias. Is there an increased risk there too? 

DR. MANN: When the person’s manic, purely manic, the risk is infinitesimal. But when they combine the mania with depression, the mixed state, then they’ve sort of got that drive and energy to do things at times when they’ve also got the depressive symptoms and the suicidal ideation. So those patients are at risk. So the goal of bipolar patients is basically to keep the depression at bay.    

DR. RAISON: Thank you. Very helpful, very fascinating.