How to Tailor Suicide Means Assessment in Hospitalized Mood Disorders
How should clinicians assess likely self-harm methods and target means restriction in hospitalized adults with major depressive disorder or bipolar disorder?
Hospitalized adults with major depressive disorder and bipolar disorder do not present with identical self-harm method patterns. This guide applies when evaluating suicide risk after self-inflicted poisoning or injury and helps clinicians focus questioning and safety planning on the methods most commonly associated with each diagnosis in this inpatient sample.
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Identify whether the current mood disorder diagnosis is MDD or BD
Start the risk assessment by clarifying whether the patient is hospitalized with major depressive disorder or bipolar disorder, because the study found different method patterns between these groups. Use the diagnosis to frame which self-harm methods warrant the highest-priority questioning rather than assuming the same risk profile across mood disorders.
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Ask directly about cutting and piercing instruments in both groups
Assess access to and recent use of cutting and piercing instruments in all hospitalized patients with MDD or BD, since this was the most prevalent self-inflicted injury method in both groups. The frequency was higher in BD than MDD, 35.5% versus 30.8% (P < .001), so this method deserves especially careful attention in bipolar disorder.
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Review medication-poisoning methods for both diagnoses
Ask specifically about access to tranquilizers and other psychotropic agents and about other specified drugs and medicinal substances, because these poisoning methods were common in both groups. Tranquilizers and other psychotropic agents occurred at nearly identical rates in BD and MDD, 29.2% versus 29.4% (P = .72), and other specified drugs and medicinal substances were also similar, 14.3% versus 14.0% (P = .546).
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Add diagnosis-specific method probes when the patient has MDD
In patients with MDD, extend the assessment to methods that were more common than in BD: analgesics, other sedatives and hypnotics, other and unspecified solid and liquid substances, and hanging by strangulation and suffocation. The reported frequencies were 16.7% versus 11% for analgesics, 4.9% versus 3.7% for other sedatives and hypnotics, 3.9% versus 3.3% for other and unspecified solid and liquid substances, and 3.7% versus 2.5% for hanging, all favoring higher prevalence in MDD.
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Screen diagnosis-linked psychiatric comorbidities during the same evaluation
Assess comorbid psychiatric conditions that differed between groups because they may refine the overall clinical picture during suicide risk evaluation. In MDD, anxiety disorders and adjustment disorders were more prevalent, while in BD, schizophrenia and other psychotic disorders and personality disorders were more prevalent.
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Prioritize restriction of the methods the patient can access
Use the methods identified in the assessment to guide means-restriction counseling, with particular focus on the most prevalent forms of self-injury and poisoning described in the study. The authors conclude that restricting access to these common methods could be a practical approach to suicide prevention, especially because patients who attempt suicide using highly lethal techniques may be more likely to use the same approach in a later fatal act.
Clinical Considerations
- The findings come from a retrospective administrative inpatient database and are vulnerable to detection, reporting, and coding bias.
- Because the dataset used discharge records rather than unique patients, the same individual may have been counted more than once.
- The study describes patterns among hospitalized adults aged 18 years or older with MDD or BD and does not establish an individual-level predictive algorithm.
- Coding errors in the deidentified database could not be individually confirmed.
Bottom Line
In hospitalized adults with mood disorders, suicide risk assessment should explicitly ask about cutting instruments and medication-poisoning methods in all patients, then add MDD-specific attention to analgesics, sedative-hypnotics, unspecified substances, and hanging when planning means restriction.
