Correspondence

Treatment of Suicidal Patients

N Engl J Med 1998; 338:261-262January 22, 1998

Article

To the Editor:

Hirschfeld and Russell's algorithm for treating suicidal patients (Sept. 25 issue)1 does not emphasize the fundamental importance of psychodynamic formulation and brief psychotherapy in clarifying and managing a suicidal crisis. Although major depression, alcohol abuse, and other psychiatric conditions have been shown to figure prominently in suicidal states, recent blows to self-esteem or disruptions of key relationships may explain why a particular patient presents in crisis at a specific time.2 Moreover, some patients, particularly those with certain personality disorders, may be so sensitive to losses that the resulting reactive depressive states may prove no less deadly than the endogenous or biologic variety. Thus, the assessment of suicidal patients must include an inventory of crucial losses, with attention paid to restorative measures.3 Problem-solving with the patient about what motivates his or her suicidality may alleviate feelings of aloneness. Helping a patient locate the suicidal anger and despair in a particular relationship difficulty may help dispel corrosive loneliness.4 I have found that family or couples therapy beginning in the emergency setting can obviate the need for hospitalization and that a suicidal patient — even after a suicide attempt — may be able to go home smiling if the breach with loved ones can be resolved on the spot.5 An understanding of the psychodynamic factors driving suicidal ideation should inform follow-up telephone calls and visits. Pharmacotherapy must never substitute for exploring the human problem.4

John Michael Bostwick, M.D.
Wilford Hall Medical Center, Lackland AFB, TX 78236

5 References

1
Hirschfeld RMA, Russell JM. Assessment and treatment of suicidal patients. N Engl J Med 1997;337:910-915
Full Text | Web of Science | Medline

2
Jorstad J. Some experience in psychotherapy with suicidal patients. Acta Psychiatr Scand Suppl 1987;336:76-81
Medline

3
Buie DH, Maltsberger JT. The practical formulation of suicide risk. Cambridge, Mass.: Firefly Press, 1983.

4
Mayer DY. A psychotherapeutic approach to the suicidal patient. Br J Psychiatry 1971;119:629-633
CrossRef | Web of Science | Medline

5
Bostwick JM, Rundell JR. Suicidality. In: Rundell JR, Wise MG, eds. Textbook of consultation–liaison psychiatry. Washington, D.C.: American Psychiatric Press, 1996:138-61.

To the Editor:

Hirschfeld and Russell do not explain that epidemiologic studies of suicide have many biases. Most suicide attempts do not lead to an interview with a physician; some suicides are reported as accidental deaths and are never included in studies.1 Specialists have access to only a fraction of those who attempt suicide. Conducting a retrospective psychological autopsy to find a diagnosis by interviewing proxies after the suicide is a method of uncertain accuracy. Moreover, confusion in suicidal situations between a diagnosis of psychosis and one of depression, and feelings of guilt, frustration, despair, or treachery are common.

Hospitalization or psychotropic treatment is often prescribed for suicidal patients. However, no study has shown that hospitalization is clearly efficacious in preventing suicide, and new psychotropic drugs do little to reduce suicide rates.2 There are multiple and complex causes of suicidal behavior. The high rates of attempts and of completed suicides may be related to the inability of professionals to elaborate credible alternative treatments. Suicide should be considered the response of someone, whether suffering from mental disease or not, who is unable to find a solution to a relational crisis. Often, suicide prevention should include members of the patient's family and social network.3

Frédéric Pochard, M.D.
Michael Robin, M.D.
Serge Kannas, M.D.
Charcot Hospital, 78373 Plaisir CEDEX, France

3 References

1
Diekstra RF. Suicide and the attempted suicide: an international perspective. Acta Psychiatr Scand Suppl 1989;354:1-24
CrossRef | Medline

2
Meltzer HY, Okayli G. Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia: impact on risk-benefit assessment. Am J Psychiatry 1995;152:183-190
Web of Science | Medline

3
Gould MS, Fisher P, Parides M, Flory M, Shaffer D. Psychosocial risk factors of child and adolescent completed suicide. Arch Gen Psychiatry 1996;53:1155-1162
Web of Science | Medline

To the Editor:

When a physician is faced with a request for assisted suicide, Hirschfeld and Russell recommend that he or she immediately determine whether the patient's pain is adequately controlled and assess the patient for treatable psychiatric disease — especially depression. I strongly agree but would add that pastoral care should also be offered.

There are spiritual and religious dimensions in medicine.1,2 Suffering and terminal illness often precipitate serious spiritual conflicts, and these conflicts can further intensify the suffering. Appropriate pastoral services can be helpful.

(The opinions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.)

Kenneth J. Simcic, M.D.
Brooke Army Medical Center, Ft. Sam Houston, TX 78234

2 References

1
Mitka M. Grants encourage med schools to add spiritual training. American Medical News. December 4, 1995.

2
Gesensway D. Making the case for bringing religion to patient care. ACP Observer. July/August 1997:5.

To the Editor:

Hirschfeld and Russell stress the importance of vigorous pharmacologic treatment of depression in suicidal patients. Unfortunately, however, nothing is said about the importance and life-saving effects of appropriate long-term treatment with lithium salts. This unique mood-stabilizing compound possesses well-documented antiaggressive effects, possibly related to its serotonin-agonistic properties. During the past decade it has been clearly demonstrated that long-term prophylaxis with lithium has preventive effects against suicide, which so far have not been shown by any other antidepressive or mood-stabilizing drugs, such as amitriptyline, selective serotonin-reuptake inhibitors, or carbamazepine.1-3 Thus, lithium can normalize the two-to-threefold increase in the standardized mortality of untreated patients with a unipolar, bipolar, or schizoaffective type of affective disorder.4 Calculations show that in my country adequate prophylaxis with lithium can save money and result in an annual increase of 3060 working years by reducing mortality from suicide.5

Bruno Müller-Oerlinghausen, M.D.
Freie Universität Berlin, D-14050 Berlin, Germany

5 References

1
Coppen A. Depression as a lethal disease: prevention strategies. J Clin Psychiatry 1994;55:Suppl:37-45
Web of Science | Medline

2
Thies-Flechtner K, Muller-Oerlinghausen B, Seibert W, Walther A, Greil W. Effect of prophylactic treatment on suicide risk in patients with major affective disorders: data from a randomized prospective trial. Pharmacopsychiatry 1996;29:103-107
CrossRef | Web of Science | Medline

3
Nilsson A. Mortality in recurrent mood disorders during periods on and off lithium: a complete population study in 362 patients. Pharmacopsychiatry 1995;28:8-13
CrossRef | Web of Science | Medline

4
Ahrens B, Muller-Oerlinghausen B, Schou M, et al. Excess cardiovascular and suicide mortality of affective disorders may be reduced by lithium prophylaxis. J Affect Disord 1995;33:67-75
CrossRef | Web of Science | Medline

5
Lehmann K, Ahrens B, Müller-Oerlinghausen B. Pharmakoökonomie der Lithiumprophylaxe. In: Müller-Oerlinghausen B, Greil W, Berghöfer. Die Lithiumtherapie. 2. Auflage. Berlin, Germany: Springer-Verlag, 1997.

Author/Editor Response

The authors reply:

To the Editor: Dr. Bostwick emphasizes the importance of careful assessment and acute diagnosis of suicidal patients. Certainly psychosocial issues, especially those involving interpersonal losses (such as death or the breakup of relationships), can serve as triggers for suicidal behavior. The clinician must also bear in mind that depression itself can cause serious pessimistic perceptual distortions of situations and relationships. Many who suffer from depression view themselves as worthless and their futures as hopeless. Appropriate treatment for depression will often correct this.

Although epidemiologic, clinical, and retrospective case studies may all have methodologic flaws, we must emphasize, in response to Pochard et al., that the overwhelming weight of the evidence shows that suicide is a consequence of psychiatric disorders, particularly depression. A core feature of depression is distorted thinking. Viewed from this perspective, suicide is not a rational choice, but an irra-tional action. Dr. Simcic's letter reminds us of the importance of spiritual and religious issues, especially for patients with terminal illness who are contemplating physician-assisted suicide.

Dr. Müller-Oerlinghausen raises two important issues regarding lithium in his letter. The first is that lithium (as well as other mood-stabilizing medications, such as valproate and carbamazepine) has antiaggressive effects. Therefore, the use of these medications, especially in people at risk for impulsive aggressive behavior, may reduce the risk of suicide. Dr. Müller-Oerlinghausen's second point involves the use of lithium as a maintenance medication in unipolar (as well as bipolar and schizoaffective) depression. This application of lithium has not been particularly widespread in the United States, probably because of the side-effect profile of lithium as compared with those of the selective serotonin-reuptake inhibitors and other newer antidepressant agents. In addition, lithium's efficacy in long-term prophylaxis is probably less than that of the newer antidepressants.1

Robert M.A. Hirschfeld, M.D.
James M. Russell, M.D.
University of Texas Medical Branch at Galveston, Galveston, TX 77555-0429

1 References

1
Prein RF, Kocsis JH. Long-term treatment of mood disorders. In: Bloom FE, Kupfer DJ, eds. Psychopharmacology: the fourth generation of progress. New York: Raven Press, 1995:1067-79.

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