Predicting Suicide: Doctors' New Assessment Tool

New research could help identify patients most likely to harm themselves.

June 16, 2011— -- The breakfast-induced suicide happened two decades ago but still haunts Dr. Igor Galynker.

He had finished medical school and was working as a resident at a New York clinic when one of the patients had a fight with her mother over whether she would get scrambled eggs or eggs sunnyside up. Directly afterward, she jumped to her death off the balcony of her 20th floor apartment.

Her doctors were surprised. Although the woman was mentally ill with schizoaffective disorder, a condition that causes mood problems and psychosis, Galynker said, the patient was seen routinely and wasn't considered acutely suicidal.

It was a wakeup call, Galynker said, for "how trivial the triggers may be and how helpless we are in predicting suicide."

But his latest research might change that. Galynker, who is the associate chairman of the Department of Psychiatry and Behavioral Sciences at Beth Israel Medical Center in New York, and who also directs the Family Center for Bipolar Disorder, is developing a series of questions that could help doctors care for suicidal patients. If his team is successful, they will have created the first tool available to help doctors predict imminent suicide attempts.

It's often assumed that patients who are planning to kill themselves are depressed, talk about killing themselves and eventually formulate a plan. In reality, doctors say, patients aren't usually so forthcoming, and their behavior isn't always premeditated; it's often impulsive.

One recent example is reality-TV star Amber Portwood, who became famous on MTV's "Teen Mom."

She reportedly fought with her daughter's father prior to being hospitalized Tuesday morning. Police in Anderson, Ind., said she was threatening to take her life.

Portwood's ex-fiance Gary Shirley called 911.

"She said, 'Call the police so they can find my body in the garage,'" he told the 911 dispatcher in an audio recording obtained by TMZ.

Star Magazine reported when paramedics arrived they found Portwood drifting in and out of consciousness and had to remove a rope from around her neck. The magazine also claimed she had admitted to taking pills.

Research indicates that the average time between thinking about suicide and actually attempting it is about 10 minutes, Galynker said.

Pathological Mental State Can Predict Suicide Attempts, Doctor Says

But Galynker says people who commit suicide do have something in common: a certain pathological state of mind that fluctuates in intensity. Defining and recognizing that mental state has been one of the great challenges faced by psychiatrists in the past 15 years, according to Dr. Tim Lineberry, chair of the inpatient Mayo Clinic psychiatry division and board chairman of the American Association of Suicidology.

"We know that psychological illness is associated with suicide but we see suicidal behavior as being something that is kind of unique to the individual and has a number of other factors," Lineberry said.

In Galynker's research, he hypothesizes that this state of mind precedes the urge to act, describing it as "really severe anxiety ... like being sucked through vortex."

Patients "try to come out, but they can't," he said.

There are three things, he says, that happen in that state: an endless cycle of hopeless thinking that cannot be controlled, the frantic sensation of being trapped and physical sensations that aren't based in reality.

Suicide Trigger Scale Aims to Predict Suicide Attempts

Identifying the patients who dwell in this state can be tricky, especially when assessment tools largely identify patients who think about suicide, not necessarily those who will make an attempt.

"We need to improve suicide risk assessment … and provide treatment that mitigates that risk," Lineberry said. "Suicidal ideation is not as helpful as people think it is," although insurance companies seem to think it is the key.

Among Galynker's 40 questions that comprise the Suicide Trigger Scale, patients are asked whether, when they're very anxious, they think their "head could explode from too many thoughts," if "there is no exit" or if "the world is closing in on you."

But the most important question, Galynker said, is the one asking "do you feel trapped."

"The way suicidal thoughts progress is as long as there is some kind of exit, there is a door, there is hope. When there is no place to go; that is where the pain becomes intolerable," he said.

He plans to survey 300 patients who are admitted to the Beth Israel Medical Center who are at a high risk for suicide or who have attempted suicide. They are then reinterviewed in two months, and again in a year.

The patients are also given another set of questions, the Symptom Checklist-90-R. Galynker believes his assessment tool will be more accurate than the SCL-90-R in predicting whether patients will attempt suicide that year.

One key difference in Galynker's questionnaire, compared to other assessment tools, is that he does not ask if the patient plans to commit suicide; instead, he's attempting to capture the feelings associated with suicidal behavior.

"Feelings are older than thoughts," he said.

Suicide Rates Rise Among the Middle-Aged

Dr. Paula Clayton, Medical Director of the American Foundation for Suicide Prevention, an organization funding Galynker's research, says suicide rates are "alarmingly up."

Before the 80s, suicide rates were high and then eventually dropped when antidepressants became widely used. But since 2004, Clayton says suicide rates started to rise again, particularly among men and women between 40 and 65 years old.

"It's scary because the highest suicide rates were always in the elderly," Clayton said.

Preliminary CDC data from 2009 now indicates suicide is the 10th leading cause of death -- it used to be 11th -- and Clayton says it's the only cause of death among the top 20 causes that rose in ranking. The same data also shows 36,547 suicides occurred in 2009, up from 34,000 in 2007.

The rise is partly because of the recession.

"There has always been a correlation between unemployment and suicide. That was clear even during the Great Depression," Clayton said.

If Galynker's Suicide Trigger Scale is effective, it might not only help patients get the help they need, but it could also help doctors, too.

"[Suicide] has a profound impact on clinicians and families," Lineberry said, "and that's part of the reason so many of us are in suicide prevention."

Suicide Prevention Resources

Click here to read facts about suicide and learn more about the many resources available to help prevent it.