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Now or Never: Short-Term Predictors for Suicide

Professor of Psychiatry, University of New Mexico School of Medicine

This interview was conducted by Peter Cook, on July 31, 2006.



America bears witness to 30,000 deaths by suicide per year. Although clinicians have a fairly good grasp of long-term risk factors, possible short term indicators of risk have been largely overlooked. Dr. Jan Fawcett believes that, to make real headway in combating suicide, doctors need to identify patients at acute, not just chronic, risk of suicide and treat their symptoms aggressively.

Dr. Fawcett has the weight of experience behind his opinion; he began researching suicide in 1964 as a fellow at the NIMH, where he and his colleagues identified the first biological indicator of suicide risk. He then opened a suicide-prevention unit in Chicago, at the hospital that would later become Rush-Presbyterian Hospital. Over the next 30 some years he was at the forefront of prospective research with suicidal patients. Recently, Dr. Fawcett has relocated to New Mexico to spend more time working with patients one on one.

“My main emphasis has always been on clinical prediction and treatment; how do we address the modifiable risk factors for suicide?” Dr. Fawcett says.

Predicting Suicide

“We have plenty of clinical associations, and even quite a few social and epidemiological associations, for suicide risk,” Dr. Fawcett says. “However, when it comes to a clinician evaluating an individual patient, things can get difficult. Most of the associations we have predict long-term risk for suicide, but clinicians needs to know what’s going to happen tomorrow. When it comes to predicting acute risk, we’re very deficient.”

Dr. Fawcett’s work has suggested that the standard risk factors taught at medical school—prior suicide attempts, suicidal ideation, hopelessness—while strong predictors of ultimate risk, aren’t of much predictive use in the short term.

“What I’ve found,” he says, “is that you often see increased anxiety and agitation and severe insomnia immediately preceding serious suicide attempts.”

Dr. Fawcett’s data suggest that increased anxiety and severe insomnia are effective predictors of short-term suicide risk in 70%–80% of hospitalized patients, although he believes the number is somewhat lower in outpatients.


“Patients at high risk are experiencing, through their anxiety and agitation, what I call ‘psychic pain’,” Dr. Fawcett says. “It’s a type of pain I don’t think anyone understands who hasn’t experienced it, but when that’s paired with hopelessness suicide can be the result.” Screening for this type of anxiety is no simple task, Dr. Fawcett explains. “Anxiety is not uncommon in depression— ≥60% of depressed patients have moderate anxiety. The real warning sign is an increase in symptoms of anxiety, but assessing the severity of anxiety goes against the current habit of classifying symptoms as either present or absent. Clinicians need to ask probing questions regarding the severity of the symptoms, and, also, find out how much of the day is spent experiencing the symptoms.”

If the patient is experiencing what the clinician determines to be extreme anxiety or insomnia, Dr. Fawcett stresses that treatment needs to be swift, targeted, and aggressive.


“A lot of doctors believe that antidepressants are going to take care of symptom severity, but this can be a deadly mistake,” Dr. Fawcett warns.

Metanalyses of FDA studies on SSRIs show that rates of suicide over 8–12 week studies are the same for placebo or drug. Over 35–40 years, there is a two and half lifetime reduction in suicide rates for patients who have had at least 6 months of steady treatment, so long-term treatment is important, but it doesn’t address immediate risks.

“Acute insomnia and severe agitation and anxiety must be treated aggressively and with the goal of eliminating the symptoms in the short-term while one is waiting for antidepressants to help the patient in the long-term,” Dr. Fawcett says. He recommends benzodiazepines, such as clonazepam, and, for those with ruminative anxiety and agitation, atypical antipsychotics, such as quetiapine and olanzapine. He also suggests that CBT is warranted for patients who are particularly prone to react with hopelessness in adverse situations.

Equally important as treatment, he believes, clinicians need to follow through. “Patients experiencing this level of distress often can’t follow directions well. Sometimes they need hospitalization or outside help to keep them on the right track.”

Personalized Treatment

Dr. Fawcett acknowledges that identifying patients at acute risk for suicide takes more work than a typical diagnosis, and may rely on a fair portion of clinical intuition.

“I’m an old-fashioned clinician,” Dr. Fawcett says. “I believe that clinicians should make an assessment individually, follow up, and talk to the patient. This is particularly important with patients at risk for suicide; impersonal rating scales often won’t clue a clinician in to the severity of what the patient is experiencing. For example, you ask some patients if they’re suffering from anxiety and they just give you a blank look. Ask them if they’ve got fears though and it might be a wholly different story. This is an area where clinical skill truly makes a difference.”

Dr. Fawcett also adds that dedication and availability are important when dealing with this patient population. “These patients are too sick to be left on their own. They might perk up when in your office, but on their own they go into a private hell. You can’t just give them a drug and expect everything to turn out fine. You need to be in constant touch with the patients, and make sure they have the support they need. It’s a serious commitment, but proper intervention saves lives.”

Disclosure: Dr. Fawcett is on the speaker’s bureau of Eli Lilly and the advisory board of Abbott.

Source: http://www.nimh.nih.gov/suicideprevention/suifact.cfm