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Re-thinking the Unthinkable

News from the Department of Psychiatry and Behavioral Science

New ideas on suicidality are changing what we do

Dr. DePaulo
Dr. Ray DePaulo

Like anorexia or the endless washing of hands, “suicidality” —talking about, planning or actual attempts at suicide—is best seen as behavior born of a biologically troubled brain in a body confronted with possibility. Though it justly rings emotional alarms as little else, says Ray DePaulo, and though it’s marked by “an especially complex interweaving of intentions, goals and action, suicidality is still, basically, behavior.” Stripping it of its allure, deconstructing it and tailoring treatment more precisely to patients under its spell, he says, is where psychiatry is headed.

DePaulo, who directs Hopkins’ Psychiatry and Behavioral Sciences, is internationally known for the sophistication of his search for bipolar disorder genes. But insiders see him also as a consummate clinician, as a man with more than two decades’ experience in helping patients with mood disorders. He’s authored at least 100 scientific articles and books. He’s a board member of the American Foundation for Suicide Prevention. His thoughts on suicidality were pulled from interviews and a recent Grand Rounds.

Q. For years, we’ve seen suicidality mostly as related to depression, haven’t we?

A. Well, about 90 percent of people who actually commit suicide have an easily diagnosed psychiatric disorder. But now we suspect it takes more than, say, severe depression. Is depression important? You bet. Powerfully so. Still, in some, there are elements besides disease—suicide is a multiple hit idea. 

Q. Elements such as?

A. Facilitators, we call them. Alcohol and drugs, for example, particularly benzodiazepines, can affect the severity of suicide attempts, perhaps because they lessen inhibitions. I find David Schaffer’s [Columbia U.] model of suicide useful: An active psychiatric disorder sets the stage, along with stressful life events and an acute mood change brought on, say, by hopelessness or shame. What tips a patient into suicide is a facilitator like being alone, being intoxicated or having access to a lethal means. 

Q. What about categories of suicidality?

A. They exist. Some patients make multiple attempts, some only one. In some, suicidality comes with drugs; in others, when patients are delusional. In some, cutting behavior plays a part. We need to study these distinct groups to see how they differ in biology, epidemiology and on as many levels as possible. 

Q. Isn’t there a progression? People go from just wishing they didn’t exist to active planning to carrying it out?

A. Sometimes there is an apparent linearity, and, yes, the risk of ultimate suicide increases somewhat with each step, but the concept itself isn’t so helpful. For one thing, the path isn’t always linear! Half of suicides occur without prior statements or acts. For another, suicidal statements and thoughts are poor predictors. What’s the likelihood that someone with any kind of attempt will commit suicide in a year’s time? It’s less than 5 percent. Of course, you’d never ignore that, but neither would you hospitalize everyone for a year, for prevention. 

Q. So, other than raising a small but real red flag for suicide, is suicidality itself a concern?

A. Absolutely! People having suicidal thoughts, statements or acts, however indirect, are clearly in trouble. They may be living in a chaotic world with unstable, unhelpful relationships. And they very much need help. That’s why, in the ER, for example, where you frequently hear patients threatening suicide, the doctor’s job isn’t simply to figure out if the threat’s real. It’s to engage the person, to help, to realize that such patients are at risk of lots of bad things—broken relationships, lost jobs, families destroyed—even more than they’re at risk of suicide. 

Q. Any other advice?

A. Yes. Be wary of formulas, shortcuts in treating suicidality. Safety contracts with patients, especially in acute care settings, can give false security; they’re not reliable. A systematic approach is crucial. What are patients thinking? Are they depressed? Catalogue personality, knowing a negative, manipulative temperament can blind you to depression. Ask about life events. Look for underlying disease. And leave nothing out.

Find other Hopkins Newsletter articles from past issues.