What is the best approach to manage a patient with a family history of depression and suicide attempts?

Managing Patients with Family History of Depression and Suicide Attempts

A family history of depression and suicide attempts significantly elevates suicide risk and mandates comprehensive psychiatric assessment with heightened vigilance, as this remains a significant independent risk factor even after controlling for parental psychopathology. 1

Risk Stratification Based on Family History

Family history creates a distinct vulnerability profile that requires specific clinical attention:

• Family history of suicidal behavior remains an independent risk factor even when controlling for effects of parental psychopathology, indicating both genetic vulnerability and environmental stressors may be operative 1
• Parental depression and substance abuse compound the risk and require assessment as part of the comprehensive evaluation 1
• The mechanism may involve both genetic predisposition (potentially related to serotonin dysregulation) and learned behavioral patterns from family environment 1

Comprehensive Assessment Algorithm

When evaluating a patient with this family history, structure your assessment systematically:

Direct Suicide Risk Assessment

Ask these specific diagnostic questions in sequence 1:

• "Did you ever feel so upset that you wished you were not alive or wanted to die?"
• "Did you ever do something that you knew was so dangerous that you could get hurt or killed by doing it?"
• "Did you ever hurt yourself or try to hurt yourself?"
• "Did you ever try to kill yourself?"
• "Did you ever think about or try to commit suicide?"

These questions do not increase suicide risk or cause suicidal thoughts 2

Evaluate Suicide Intent and Planning

Beyond ideation, assess the depth of planning 1, 2:

• Determine if the patient has taken steps to conceal behavior and avoid discovery
• Assess whether specific plans have been formulated (e.g., "Did you do anything to get ready to kill yourself? Did you think what you did would kill you?")
• Evaluate motivating feelings: wish to gain attention, escape intolerable situations, rejoin deceased relatives, or seek revenge 1
• Critical caveat: Children and adolescents systematically overestimate the lethality of different suicidal methods, so significant intent may exist despite choosing non-lethal methods 1

Assess Current Mental State

Document these high-risk features that require immediate intervention 1:

• Irritability, agitation, threatening violence, delusions, or hallucinations indicate high short-term risk
• Hopelessness is a critical risk factor and predictor of treatment dropout 1
• Rapid mood shifts from depression, anxiety, and rage to euthymia/mania, potentially with transient psychotic symptoms 1
• Comorbid substance abuse, which often co-occurs with mood disorders and significantly increases risk 1

Evaluate Access to Lethal Means

Determining access to suicide methods is vital, particularly 1, 2:

• Firearms in the home (highest lethality at 85% case-fatality rate) 1
• Medications that could be used for overdose 1, 2
• Other lethal means based on patient's stated plan 1

Decision Algorithm for Level of Care

Criteria Requiring Inpatient Psychiatric Admission

Hospitalize immediately if any of the following are present 1, 2:

• Persistent wish to die despite intervention
• Clearly abnormal mental state, especially with irritability, agitation, threatening violence, delusions, or hallucinations
• Current mental disorder complicated by comorbid substance abuse
• Prior suicide attempts, particularly using lethal methods (methods other than ingestion or superficial cutting)
• Male gender, especially ages 16-19 or older adults
• Patient cannot engage in discussion around safety planning
• Inadequate support system or inability to be adequately monitored
• High-lethality suicide attempt or attempt with clear expectation of death 1

Outpatient Management Criteria

Patients may be considered for outpatient management if 1:

• No persistent desire to die after evaluation
• Able to participate meaningfully in safety planning
• Adequate support system with responsible adult supervision
• Access to timely outpatient mental health follow-up
• Lethal means can be secured (firearms removed, medications locked)

Common pitfall: Do not rely on "no-suicide contracts" as they have no proven efficacy in preventing suicide and may impair therapeutic engagement 1, 2

Safety Planning for Discharge

If outpatient management is appropriate, implement comprehensive safety planning 1:

Essential Components

1. Identification of warning signs and triggers for recurrence of suicidal ideation
2. Specific coping strategies the patient can use if suicidal ideation returns
3. Healthy activities for distraction or suppression of suicidal thoughts
4. Names and contact information of responsible social supports the patient can turn to
5. Professional support contact information, including how to reaccess emergency services
6. Means restriction counseling is fundamental 1

Means Restriction Counseling

This is a key component because most suicide attempts are impulsive 1:

• 24% of patients go from deciding to attempt suicide to implementing within 0-5 minutes 1
• Wide variation in case-fatality rates: 85% for firearms, 2% for ingestions, 1% for cutting 1
• Confirm a responsible adult has agreed to remove firearms and lethal medications from the home 2
• Increasing time and effort required to access lethal means provides opportunity for reconsideration or intervention 1

Treatment Approach

Psychiatric Diagnosis and Treatment

Address underlying psychiatric conditions aggressively 1:

• Depression is present in 50-79% of youth suicide attempts and doubles odds in adults 2
• Bipolar disorder, mania, hypomania, or mixed states require immediate identification 1, 3
• Substance abuse disorders must be treated concurrently 1
• Consider cognitive-behavioral therapy focused on suicide prevention for patients with suicidal ideation 4

Pharmacotherapy Considerations

When prescribing antidepressants in this high-risk population 5:

• Monitor closely for clinical worsening, suicidality, and unusual changes in behavior, especially during initial months or dose changes
• Watch for emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, or mania 5
• Families and caregivers must be alerted to monitor for agitation, irritability, unusual behavior changes, and emergence of suicidality 5
• Prescribe smallest quantity consistent with good management to reduce overdose risk 5

Follow-Up Planning

The greatest risk of reattempting suicide is in the months after initial presentation 1:

• Schedule immediate follow-up appointment before discharge 2
• Emphasize importance of consistent follow-up as counseling takes time to work 1
• Ensure adequate supervision and support will be available 2
• Consider partial hospital programs, intensive outpatient services, or in-home crisis stabilization when more intensive treatment is needed 1

Documentation Requirements

Document thoroughly to guide ongoing care 2:

• Estimate of patient's suicide risk with specific factors influencing that risk
• Rationale for treatment selection, including factors that influenced the choice
• Family history details: specific psychiatric diagnoses, suicide attempts, substance abuse in family members 1
• Current mental state and response to interventions 1

Critical Pitfalls to Avoid

• Do not rely solely on structured suicide scale questionnaires, as they have limited predictive value 2
• Never discharge patients with irritability, agitation, threatening violence, delusions, or hallucinations without psychiatric evaluation 2
• Avoid coercive communications like "you can't leave until you say you're not suicidal," as this encourages deceit and undermines therapeutic alliance 2
• Do not place excessive confidence in "no-suicide contracts" as their value is unproven 2
• Do not perform routine laboratory or radiographic testing unless indicated by history and physical examination 1