As the world grapples to understand what would drive a talented and successful super-star like Robin Williams to take his own life, many of us who treat depressed patients everyday are left with our own nagging questions.
How can one really know if a patient in on the verge of suicide? Are the signs always present? After all, Mr. Williams was receiving treatment for depression and substance abuse at the time of his tragic death, and had just the previous month spent time in a rehab program.
Sadly, the fact that Mr. Williams committed suicide while receiving mental health treatment is not surprising. Most individuals who die by suicide have visited a health care provider three months to a year before their death, according to the National Institute of Mental Health.
It is this frightening realization that we are coming into contact with these individuals and are somehow unable to save them that has prompted decades of research on suicide risk factors.
Unfortunately, the list of risk factors is not a short one. It includes specific signs and symptoms, psychiatric co-morbidities, numerous psychosocial stressors, and various physical disorders.
Although many have long attested to the notion that a history of suicide attempt is the strongest predictor of future suicide attempts, others warn us of those impulsive, anxious and depressed patients with a seemingly acute onset of symptoms that make serious attempts as well.
There does seem to be a general consensus in the literature that most patients that commit suicide have a history of a mental illness – as many as 90%. Co-morbid alcohol or substance use poses a huge risk, especially in impulsive suicides.
Common psychiatric symptoms associated with increased suicide risk include: hopelessness, loss of pleasure or interest, insomnia, pain, and anxiety or agitation.
A minority of patients may have chronic suicidal thoughts that ultimately lead to plans and actions, but many patients experience significant psychosocial stressors that cause severe distress preceding suicide.
We also are now more aware of the association of depression with certain physical disorders such as epilepsy, cardiovascular disease, cancer, and autoimmune diseases. There a numerous assessment tools available to providers that can help screen for risk factors.
However, despite a greater recognition of depression as an authentic medical illness, our efforts to better understand suicide risk factors, and initiatives to decrease stigma and improve access to mental health care, depression remains one of the most debilitating illnesses in our country.
Suicide continues to plague Americans both young and old. We owe it to our patients and ourselves to remain cognizant of the potential lethality of depression and to continue the search for answers to those difficult questions.
Melissa Vallas, MD, is lead psychiatrist at Children’s System of Care, Alameda County (California) Behavioral Health Care Services Agency.