Full Ebook of Textbook of Suicide Risk Assessment and Management 3Rd Ed Liza H Gold Online PDF All Chapter

Textbook of Suicide Risk Assessment
and Management 3rd ed Liza H. Gold

Visit to download the full and correct content document:
https://ebookmeta.com/product/textbook-of-suicide-risk-assessment-and-managemen
t-3rd-ed-liza-h-gold/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
The Global Human Resource Management Casebook 3rd

Edition Liza Castro Christiansen
https://ebookmeta.com/product/the-global-human-resource-
management-casebook-3rd-edition-liza-castro-christiansen/
Project Management for IT Related Projects 3rd ed Bob

Hughes (Ed.)
https://ebookmeta.com/product/project-management-for-it-related-
projects-3rd-ed-bob-hughes-ed/
Assessment and Management of Pressure Injuries for the

Interprofessional Team 3rd Edition Sibbald G.
https://ebookmeta.com/product/assessment-and-management-of-
pressure-injuries-for-the-interprofessional-team-3rd-edition-
sibbald-g/
Oxford Textbook of Suicidology and Suicide Prevention

(Oxford Textbooks in Psychiatry) 2nd Edition Danuta
Wasserman
https://ebookmeta.com/product/oxford-textbook-of-suicidology-and-
suicide-prevention-oxford-textbooks-in-psychiatry-2nd-edition-
danuta-wasserman/
The Security Risk Assessment Handbook: A Complete Guide
for Performing Security Risk Assessments 3rd Edition
Douglas J. Landoll
https://ebookmeta.com/product/the-security-risk-assessment-
handbook-a-complete-guide-for-performing-security-risk-
assessments-3rd-edition-douglas-j-landoll/
Textbook Of Polytrauma Management: A Multidisciplinary

Approach 3rd Edition Hans-Christoph Pape And Others
https://ebookmeta.com/product/textbook-of-polytrauma-management-
a-multidisciplinary-approach-3rd-edition-hans-christoph-pape-and-
others/
Suicide Assessment and Treatment Planning A Strengths

Based Approach 1st Edition Sommers-Flanagan
https://ebookmeta.com/product/suicide-assessment-and-treatment-
planning-a-strengths-based-approach-1st-edition-sommers-flanagan/
Assessment and Communication of Risk 1st Edition Eric

Liberda Timothy Sly
https://ebookmeta.com/product/assessment-and-communication-of-
risk-1st-edition-eric-liberda-timothy-sly/
Fundamentals of Risk Management: Understanding,

Evaluating and Implementing Effective Enterprise Risk
Management 6th Edition Clive Thompson
https://ebookmeta.com/product/fundamentals-of-risk-management-
understanding-evaluating-and-implementing-effective-enterprise-
risk-management-6th-edition-clive-thompson/
T H I R D E D I T I O N
The American Psychiatric Association Publishing
TEXTBOOK of
SUICIDE RISK ASSESSMENT
and MANAGEMENT
Edited by
Liza H. Gold, M.D.
Richard L. Frierson, M.D.
THE AMERICAN PSYCHIATRIC ASSOCIATION PUBLISHING
TEXTBOOK OF
AND MANAGEMENT
THE AMERICAN PSYCHIATRIC ASSOCIATION PUBLISHING
TEXTBOOK OF
AND MANAGEMENT
EDITED BY
Liza H. Gold, M.D.

Note: The authors have worked to ensure that all information in this book is accurate at the
time of publication and consistent with general psychiatric and medical standards, and that in
formation concerning drug dosages, schedules, and routes of administration is accurate at the
time of publication and consistent with standards set by the U.S. Food and Drug Administra
tion and the general medical community. As medical research and practice continue to ad
vance, however, therapeutic standards may change. Moreover, specific situations may require
a specific therapeutic response not included in this book. For these reasons and because human
and mechanical errors sometimes occur, we recommend that readers follow the advice of phy
sicians directly involved in their care or the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the findings, con
clusions, and views of the individual authors and do not necessarily represent the policies and
opinions of American Psychiatric Association Publishing or the American Psychiatric Associ
ation.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/
specialdiscounts for more information.
Copyright © 2020 American Psychiatric Association Publishing
ALL RIGHTS RESERVED
Third Edition
Manufactured in the United States of America on acid-free paper
24 23 22 21 20 5 4 3 2 1
American Psychiatric Association Publishing
800 Maine Avenue SW
Suite 900
Washington, DC 20024-2812
www.appi.org
Library of Congress Cataloging-in-Publication Data
Names: Gold, Liza H., 1958- editor. | Frierson, Richard L., editor. | American Psychiatric
Association Publishing, publisher.
Title: The American Psychiatric Association Publishing textbook of suicide risk assessment and
management / edited by Liza H. Gold, Richard L. Frierson.
Other titles: American Psychiatric Publishing textbook of suicide assessment and management.
| Textbook of suicide risk assessment and management
Description: Third edition. | Washington : American Psychiatric Association Publishing, [2020]
| Preceded by The American Psychiatric Publishing textbook of suicide assessment and
management / edited by Robert I. Simon, Robert E. Hales. 2nd ed. c2012. | Includes
bibliographical references and index.
Identifiers: LCCN 2019039725 (print) | LCCN 2019039726 (ebook) | ISBN 9781615372232
(hardcover) | ISBN 9781615372843 (ebook)
Subjects: MESH: Suicide—prevention & control | Suicide—psychology | Risk Assessment—
methods | Mental Disorders—complications
Classification: LCC RC569 (print) | LCC RC569 (ebook) | NLM WM 165 |
DDC 616.85/8445—dc23
LC record available at https://lccn.loc.gov/2019039725
LC ebook record available at https://lccn.loc.gov/2019039726
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Liza H. Gold, M.D.
PART I
Suicide Risk Assessment
and Treatment
1 Suicide Risk Assessment. . . . . . . . . . . . . . . . . . . . . . 3

Liza H. Gold, M.D.
2 Psychopharmacology and Neuromodulation . . . . . . 17

Robert L. Trestman, Ph.D., M.D.
Anita S. Kablinger, M.D., CPI, FAAP, FAPA, FACRP
3 Cognitive and Behavioral Therapy . . . . . . . . . . . . . . 29

Amy Wenzel, Ph.D., ABPP
Abby Adler, Ph.D.
4 Psychodynamic Treatment. . . . . . . . . . . . . . . . . . . . 41
Andreea L. Seritan, M.D.
Katherine A. Straznickas, Ph.D.
Glen O. Gabbard, M.D.
5 Split Treatment: The Psychiatrist’s Role . . . . . . . . . 51

Richard Balon, M.D.
6 Cultural Humility and Structural Competence in
Suicide Risk Assessment . . . . . . . . . . . . . . . . . . . . . 65
Poh Choo How, M.D., Ph.D.
Christine Kho, M.D.
Ruth Shim, M.D., M.P.H.
PART II
Major Mental Disorders
7 Depressive Disorders . . . . . . . . . . . . . . . . . . . . . . . . 83
Ryan Holliday, Ph.D.
Lindsey L. Monteith, Ph.D.
Sarra Nazem, Ph.D.
Hal S. Wortzel, M.D.
8 Anxiety Disorders, Obsessive-Compulsive

Disorder, and Posttraumatic Stress Disorder . . . . . . 95
Britta Klara Ostermeyer, M.D., M.B.A., FAPA
Rachel Funk-Lawler, Ph.D.
Jedidiah Perdue, M.D., M.P.H.
9 Substance-Related Disorders . . . . . . . . . . . . . . . . 109

Rebecca A. Payne, M.D.
10 Bipolar Spectrum Disorders . . . . . . . . . . . . . . . . . . 123

Victoria Cosgrove, Ph.D.
Trisha Suppes, M.D., Ph.D.
Ayal Schaffer, M.D.
Alaina Baker, B.S.
Nicole Kramer, M.S.
11 Schizophrenia and Other Psychotic Disorders. . . . 135
Kimberly Brandt, D.O.
Lindsey Schrimpf, M.D.
John Lauriello, M.D.
12 Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . 147

Juan José Carballo, M.D.
Paula Padierna, M.D.
Barbara Stanley, Ph.D.
Beth S. Brodsky, Ph.D.
Maria A. Oquendo, M.D.
13 Sleep and Suicide . . . . . . . . . . . . . . . . . . . . . . . . . 159

Antonio Fernando, M.D., ABPN
Kieran Kennedy, M.B.Ch.B., B.Sc.
PART III
Treatment Settings
14 Emergency Services . . . . . . . . . . . . . . . . . . . . . . . 175

Dexter Louie, M.D.
Divy Ravindranath, M.D., M.S., FACLP
15 Outpatient Treatment of the Suicidal Patient . . . . . 189

James C. West, M.D.
Derrick A. Hamaoka, M.D.
Robert J. Ursano, M.D.
16 Inpatient Treatment . . . . . . . . . . . . . . . . . . . . . . . . 201

17 Civil Commitment . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Annette Hanson, M.D.
PART IV
Special Populations
18 Children and Adolescents . . . . . . . . . . . . . . . . . . . 227

Cheryl D. Wills, M.D.
19 College and University Students . . . . . . . . . . . . . . 239

Peter Ash, M.D.
20 Suicide in the Elderly Population . . . . . . . . . . . . . . 251

Marilyn Price, M.D.
Pamela Howard, M.D., M.B.A.
21 Jails and Prisons . . . . . . . . . . . . . . . . . . . . . . . . . . 265

Jeffrey L. Metzner, M.D.
Lindsay M. Hayes, M.S.
22 Military Personnel and Veterans . . . . . . . . . . . . . . 279

Kaustubh G. Joshi, M.D.
Brian W. Writer, D.O.
Elspeth Cameron Ritchie, M.D., M.P.H.
23 Suicide and Gender . . . . . . . . . . . . . . . . . . . . . . . . 293

Navneet Sidhu, M.D.
Susan Hatters Friedman, M.D.
24 Self-Injurious Behavior . . . . . . . . . . . . . . . . . . . . . . 305

Michele Berk, Ph.D.
Claudia Avina, Ph.D.
Stephanie Clarke, Ph.D.
PART V
Special Topics
25 Social Media and the Internet . . . . . . . . . . . . . . . . 321

Patricia R. Recupero, J.D., M.D.
26 Physician-Assisted Dying. . . . . . . . . . . . . . . . . . . . 335

Nathan Fairman, M.D., M.P.H.
27 Suicide Risk Management:

Mitigating Professional Liability . . . . . . . . . . . . . . 351
Donna Vanderpool, M.B.A., J.D.
28 The Psychological Autopsy and

Retrospective Evaluation of Suicidal Intent . . . . . . 363
Charles L. Scott, M.D.
Phillip Resnick, M.D.
PART VI
Prevention
29 Suicide and Firearms . . . . . . . . . . . . . . . . . . . . . . . 379

Liza H. Gold, M.D.
30 Suicide Prevention Programs. . . . . . . . . . . . . . . . . 391

Peter Yellowlees, M.B.B.S., M.D.
Benjamin Liu, M.D.
31 Teaching Suicide Risk Assessment in

Psychiatric Residency Training . . . . . . . . . . . . . . . 403
Ashley Blackmon Jones, M.D.
PART VII
Aftermath of Suicide
32 Psychiatrist Reactions to
Patient Suicide and the Clinician’s Role. . . . . . . . . 419
Michael Gitlin, M.D.
Katrina DeBonis, M.D.
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Contributors
Abby Adler, Ph.D.
Associate, Main Line Center for Evidence-Based Psychotherapy, Bryn Mawr, Penn
sylvania; Assistant Professor, The Catholic University, Washington, DC
Peter Ash, M.D.

Professor and Director, Psychiatry and Law Service, Emory University School of
Medicine, Atlanta, Georgia
Claudia Avina, Ph.D.

Assistant Professor, Harbor-UCLA Medical Center and David Geffen School of Med
icine at UCLA, Los Angeles, California
Alaina Baker, B.S.

Research Assistant, Department of Psychiatry and Behavioral Sciences, Stanford Uni
versity School of Medicine, Stanford, California
Richard Balon, M.D.

Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology,
Wayne State University School of Medicine, Detroit, Michigan
Michele Berk, Ph.D.

Assistant Professor, Stanford University School of Medicine, Stanford, California
Kimberly Brandt, D.O.

Assistant Professor, Department of Psychiatry, University of Missouri, Columbia,
Missouri
Beth S. Brodsky, Ph.D.

New York State Psychiatric Institute and Vagelos College of Physicians and Surgeons,
Columbia University, New York, New York
Juan José Carballo, M.D.

Department of Child and Adolescent Psychiatry, Hospital General Universitario Gre
gorio Marañón, CIBERSAM, Instituto de Investigación Sanitaria Gregorio Marañón
(IiSGM), School of Medicine, Universidad Complutense, Madrid, Spain
Stephanie Clarke, Ph.D.

Clinical Instructor, Stanford University School of Medicine, Stanford, California
Victoria Cosgrove, Ph.D.

Clinical Associate Professor, and Director, Prevention and Intervention Laboratory,
Department of Psychiatry and Behavioral Sciences, Stanford University School of
Medicine, Stanford, California
Katrina DeBonis, M.D.

Assistant Clinical Professor, and Director of Residency Education, Geffen School of
Medicine at UCLA, Los Angeles, California
xi
xii Textbook of Suicide Risk Assessment and Management, Third Edition
Nathan Fairman, M.D., M.P.H.

Director, Supportive Oncology and Survivorship, Comprehensive Cancer Center; As
sistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Univer
sity of California, Davis School of Medicine, Sacramento, California
Antonio Fernando, M.D., ABPN

Consultant Psychiatrist, Senior Lecturer in Psychological Medicine, University of
Auckland, Auckland, New Zealand
Susan Hatters Friedman, M.D.

The Phillip Resnick Professor of Forensic Psychiatry, Professor of Reproductive Biol
ogy, Adjunct Professor of Law, and Professor of Pediatrics, Case Western Reserve
University, Cleveland, Ohio; Associate Professor of Psychological Medicine, Univer
sity of Auckland, New Zealand

Alexander G. Donald Professor and Vice Chair for Education, Department of Neuro
psychiatry and Behavioral Science, University of South Carolina School of Medicine,
Columbia, South Carolina
Rachel Funk-Lawler, Ph.D.

Assistant Professor, Department of Psychiatry and Behavioral Sciences and Stephen
son Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City,
Oklahoma
Glen O. Gabbard, M.D.

Clinical Professor of Psychiatry, Baylor College of Medicine, Houston, Texas
Michael Gitlin, M.D.

Distinguished Professor of Clinical Psychiatry, Geffen School of Medicine at UCLA,
Los Angeles, California
Liza H. Gold, M.D.

Clinical Professor of Psychiatry, Georgetown University School of Medicine, Wash
ington, DC
Derrick A. Hamaoka, M.D.

Associate Professor of Psychiatry, and Scientist, Center for the Study of Traumatic
Stress, Department of Psychiatry, Uniformed Services University, School of Medicine,
Bethesda, Maryland
Annette Hanson, M.D.

Assistant Clinical Professor, and Director, Forensic Psychiatry Fellowship, University
of Maryland School of Medicine, Baltimore, Maryland
Lindsay M. Hayes, M.S.

Project Director, National Center on Institutions and Alternatives, Mansfield, Mas
sachusetts
Ryan Holliday, Ph.D.

Advanced Postdoctoral Fellow, Rocky Mountain MIRECC; Instructor of Psychiatry,
University of Colorado Anschutz Medical Campus, Aurora, Colorado
Contributors xiii
Poh Choo How, M.D., Ph.D.

Health Sciences Assistant Clinical Professor, Department of Psychiatry and Behav
ioral Sciences, University of California, Davis, Sacramento, California
Pamela Howard, M.D., M.B.A.

President, Howard Medical Corporation; and President, World Health Information
Network, San Clemente, California
Ashley Blackmon Jones, M.D.

Associate Professor of Clinical Psychiatry, and Director, General Psychiatry Resi
dency, Department of Neuropsychiatry and Behavioral Science, University of South
Carolina School of Medicine, Columbia, South Carolina
Kaustubh G. Joshi, M.D.

Associate Professor of Clinical Psychiatry, Department of Neuropsychiatry and Behav
ioral Science, University of South Carolina School of Medicine, Columbia, South Carolina

Professor, and Program Director, Clinical Trials Research, Department of Psychiatry
and Behavioral Medicine, Virginia Tech/Carilion School of Medicine and Carilion
Clinic, Roanoke, Virginia
Kieran Kennedy, M.B.Ch.B., B.Sc.

Senior Psychiatry Registrar, Department of Consultation-Liaison and Emergency
Psychiatry, The Alfred Hospital, Melbourne, Australia
Christine Kho, M.D.

Resident Physician, Combined Internal Medicine/Psychiatry Residency Training Pro
gram, University of California, Davis, Sacramento, California
Nicole Kramer, M.S.

Research Assistant, Department of Psychiatry and Behavioral Sciences, Stanford
University School of Medicine, Stanford, California
John Lauriello, M.D.

Robert J. Douglas, MD, and Betty Douglas Distinguished Professor in Psychiatry, Depart
ment of Psychiatry, University of Missouri, Columbia, Missouri
Benjamin Liu, M.D.

Resident in Psychiatry, Department of Psychiatry, University of California, Davis,
Sacramento, California
Dexter Louie, M.D.

Resident Psychiatrist, Department of Psychiatry and Behavioral Sciences, Stanford
University School of Medicine, Stanford, California
Jeffrey L. Metzner, M.D.

Clinical Professor of Psychiatry, School of Medicine, University of Colorado, Denver,
Colorado
Lindsey L. Monteith, Ph.D.

Clinical Research Psychologist, Rocky Mountain MIRECC; Assistant Professor of Psy
chiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado
xiv Textbook of Suicide Risk Assessment and Management, Third Edition
Sarra Nazem, Ph.D.

Clinical Research Psychologist, Rocky Mountain MIRECC; Assistant Professor of
Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School
of Medicine, Aurora, Colorado
Maria A. Oquendo, M.D.
Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
Britta Klara Ostermeyer, M.D., M.B.A., FAPA
Professor and Chairman, The Paul and Ruth Jonas Chair in Mental Health; Chief of
Psychiatry, OU Medicine; and Mental Health Authority, Oklahoma City Detention
Center, Oklahoma City, Oklahoma
Paula Padierna, M.D.
Department of Psychiatry, Hospital La Princesa, Madrid, Spain
Rebecca A. Payne, M.D.
Associate Professor, Department of Neuropsychiatry and Behavioral Science, Univer
sity of South Carolina, Columbia, South Carolina
Jedidiah Perdue, M.D., M.P.H.
Director, Mental Health Services, Stephenson Cancer Center; and Assistant Professor,
University of Oklahoma College of Medicine, Department of Psychiatry and Behav
ioral Sciences, Oklahoma City, Oklahoma
Marilyn Price, M.D.
Assistant Professor of Psychiatry, Harvard Medical School; Member, Law and Psychi
atry Service, Massachusetts General Hospital, Boston, Massachusetts
Divy Ravindranath, M.D., M.S., FACLP
Clinical Associate Professor (Affiliated), Department of Psychiatry and Behavioral Sci
ences, Stanford University School of Medicine, Stanford; Assistant Director of Inpatient
Mental Health, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
Patricia R. Recupero, J.D., M.D.
Clinical Professor of Psychiatry, Warren Alpert Medical School of Brown University;
and Senior Vice President for Education and Training, Care New England Health
System, Providence, Rhode Island
Phillip Resnick, M.D.
Professor of Psychiatry, Case Western Reserve University, Cleveland, Ohio
Elspeth Cameron Ritchie, M.D., M.P.H.
Chair of Psychiatry, Medstar Washington Hospital Center; Professor of Psychiatry,
Uniformed Services University of the Health Sciences, Bethesda, Maryland; Vice
Chair of Psychiatry, Georgetown University School of Medicine; and Clinical Profes
sor of Psychiatry, George Washington University School of Medicine, Washington, DC
Ayal Schaffer, M.D.
Associate Professor, Department of Psychiatry, University of Toronto; and Head, Mood
and Anxiety Disorders Program, Sunnybrook Health Sciences Centre, Toronto, Ontario
Lindsey Schrimpf, M.D.

Assistant Professor of Clinical Psychiatry, Department of Psychiatry, University of
Missouri, Columbia, Missouri
Contributors xv
Charles L. Scott, M.D.

Professor of Clinical Psychiatry, University of California, Davis, Sacramento, California
Andreea L. Seritan, M.D.

Professor of Clinical Psychiatry, University of California, San Francisco, San Francisco,
California
Ruth Shim, M.D., M.P.H.

Luke and Grace Kim Professor in Cultural Psychiatry and Associate Professor of
Clinical Psychiatry, Department of Psychiatry and Behavioral Sciences, University of
California, Davis, Sacramento, California
Navneet Sidhu, M.D.

Teaching Faculty, St. Elizabeth’s Hospital Forensic Psychiatry Fellowship Program,
Washington, DC
Barbara Stanley, Ph.D.

New York State Psychiatric Institute and Vagelos College of Physicians and Surgeons,
Columbia University, New York, New York
Katherine A. Straznickas, Ph.D.

Volunteer Associate Clinical Professor, University of California, San Francisco, San
Francisco, California
Trisha Suppes, M.D., Ph.D.

Professor, Department of Psychiatry and Behavioral Sciences, Stanford University
School of Medicine, Stanford; and Director, Bipolar and Depression Research Program,
Veterans Health Administration Palo Alto Healthcare System, Palo Alto, California
Robert L. Trestman Ph.D., M.D.

Professor and Chair of Psychiatry and Behavioral Medicine, Virginia Tech/Carilion
School of Medicine and Carilion Clinic, Roanoke, Virginia
Robert J. Ursano, M.D.

Professor of Psychiatry and Neuroscience, and Director, Center for the Study of Trau
matic Stress, Department of Psychiatry, Uniformed Services University School of Med
icine, Bethesda, Maryland
Donna Vanderpool, M.B.A., J.D.

Vice President, Risk Management, Professional Risk Management Services, Inc. (PRMS),
Arlington, Virginia
Amy Wenzel, Ph.D., ABPP

Director, Main Line Center for Evidence-Based Psychotherapy, Bryn Mawr, Pennsylvania
James C. West, M.D.

Associate Professor of Psychiatry, and Scientist, Center for the Study of Traumatic
Stress, Department of Psychiatry, Uniformed Services University School of Medicine,
Bethesda, Maryland
Cheryl D. Wills, M.D.

Director, Child and Adolescent Forensic Psychiatric Services, Department of Psychiatry,
University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio
xvi Textbook of Suicide Risk Assessment and Management, Third Edition
Hal S. Wortzel, M.D.

Director, Neuropsychiatric Consultation Services, Rocky Mountain MIRECC; Michael
K. Cooper Professor of Neurocognitive Disease, and Associate Professor of Psychiatry,
Neurology, and Physical Medicine and Rehabilitation, University of Colorado School of
Medicine, Aurora, Colorado
Brian W. Writer, D.O.

Staff Inpatient Psychiatrist, Audie L. Murphy Veterans Affairs Medical Center; and
Adjunct Assistant Professor, Department of Psychiatry, University of Texas Health
Science Center, San Antonio, Texas
Peter Yellowlees, M.B.B.S., M.D.

Chief Wellness Officer, UC Davis Health; Professor of Psychiatry and Vice Chair for
Faculty Development, Department of Psychiatry, University of California, Davis,
Sacramento, California
Disclosure of Interests
The following contributors to this book have indicated a financial interest in or other affiliation
with a commercial supporter, a manufacturer of a commercial product, a provider of a commer
cial service, a nongovernmental organization, and/or a government agency, as listed below:
Peter Ash, M.D. Consultant: Provides forensic psychiatric consultation to attorneys
and courts on a variety of issues, including cases of malpractice arising from a com
pleted suicide.
Antonio Fernando, M.D., ABPN Speaker: Paid speaker for Teva Pharmaceuticals in
a CME on Hypersomnia in Melbourne, Australia.
Pamela Howard, M.D., M.B.A. President and majority shareholder, World Health
Information Network (WHIN), a telehealth platform company. Grants: WHIN was re
cently awarded two Department of Health and Human Services/National Institutes
of Health grants to detect and prevent suicidal behavior, ideation, and self-harm in
youth who are in contact with the juvenile justice system and to develop applied re
search toward zero-suicide health care systems.
Ashley Blackmon Jones, M.D. Study/Research support: Alpha Genomix Laborato
ries. Principal investigator studying use of pharmacogenomic testing to guide treat
ment for anxiety and depression.
The following contributors to this book indicated that they have no competing interests or af
filiations to declare:
Richard Balon, M.D.; Michele Berk, Ph.D.; Susan Hatters Friedman, M.D.; Richard L.
Frierson, M.D.; Rachel Funk-Lawler, Ph.D.; Glen O. Gabbard, M.D.; Michael Gitlin,
M.D.; Liza H. Gold, M.D.; Annette Hanson, M.D.; Lindsay M. Hayes, M.S.; Kaustubh
G. Joshi, M.D.; Dexter Louie, M.D.; Jeffrey L. Metzner, M.D.; Britta Klara Ostermeyer,
M.D., M.B.A., FAPA; Rebecca A. Payne, M.D.; Jedidiah Perdue, M.D., M.P.H.; Marilyn
Price, M.D.; Patricia R. Recupero, J.D., M.D.; Elspeth Cameron Ritchie, M.D., M.P.H.;
Andreea L. Seritan, M.D.; Navneet Sidhu, M.D.; Katherine A. Straznickas, Ph.D.; Tri
sha Suppes, M.D., Ph.D.; Robert L. Trestman Ph.D., M.D.; Donna Vanderpool, M.B.A.,
J.D.; Cheryl D. Wills, M.D.; Brian W. Writer, D.O.; Peter Yellowlees, M.B.B.S., M.D.
Introduction
Liza H. Gold, M.D.
Education of mental health professionals and non–mental health physicians is a

critical component in addressing the serious public health problem of suicide in the
United States. We are pleased to offer this third edition of the American Psychiatric
Association Publishing Textbook of Suicide Risk Assessment and Management in the inter
est of improving the ability to address the problem of suicide and contributing to the
education of psychiatrists as well as other mental and medical health professionals.
Mental health treatment can decrease rates of death from suicide and suicide attempts
by recognizing and treating suicide risk factors and associated mental illness. When
physicians identify patients at risk of death from suicide by asking about evidence-based
risk factors, such as mental illness and substance use, suicide mortality decreases (Mann
et al. 2005; Parra-Uribe et al. 2017). To date, all comprehensive approaches to suicide
prevention demonstrated to reduce suicide rates include the training of health profes
sionals as a critical component of their strategies (Mann et al. 2005; Schmitz et al. 2012).
Suicide risk assessment and management is a core competency (Jacobs et al. 2003;
Rudd 2014; Simon 2012) for psychiatrists (Accreditation Council for Graduate Medi
cal Education 2019) and psychologists (Cramer et al. 2013). Suicide risk assessment
(SRA) training can enhance clinicians’ knowledge, practical skills, and attitudes (Ja
cobson et al. 2012; McNiel et al. 2008; Pisani et al. 2011; Schmitz et al. 2012). Neverthe
less, regardless of specialty, mental health professionals often lack basic skills and
adequate training in SRA and do not regularly and systematically assess suicide risk
(Cramer et al. 2013; Jacobson et al. 2012; Schmitz et al. 2012; Silverman 2014).
Primary care physicians also play a significant role in identifying and providing
care for potentially suicidal patients (Luoma et al. 2002). Nevertheless, depression
and other psychiatric disorders are underrecognized and undertreated in the primary
care setting (Mann et al. 2005). Even when seeing patients with depressive symptoms,
primary care physicians do not consistently inquire about suicidal ideation or plans
(Graham et al. 2011). These findings have led to recommendations for increased train
ing of primary care physicians in the recognition and management of suicide risk
(Mann et al. 2005).
xvii
xviii Textbook of Suicide Risk Assessment and Management, Third Edition
Suicide and Public Health

The need to improve training and skills in suicide risk assessment and management
is imperative. Suicide is the tenth leading cause of death in the United States, the sec
ond leading cause of death for persons aged 10–34, and the fourth leading cause of
death for those aged 35–54. Since 2009, the number of suicide deaths per year in the
United States has surpassed the yearly total of deaths due to motor vehicle accidents
(Centers for Disease Control and Prevention 2017a). In 2017, 47,173 people died from
suicide. Of these, almost 2,500 were between the ages of 15 and 19; an additional
11,700 were between the ages of 20 and 34 (Centers for Disease Control and Preven
tion 2017b).
Even more disturbing is the fact that the age-adjusted U.S. suicide rate has increased
33%, from 10.5 per 100,000 in 1999 to 14.0 in 2017 (Hedegaard et al. 2018). Among U.S.
women, the rate of deaths from suicide increased from 4.0 per 100,000 in 1999 to 6.1 in
2017 and the rate for U.S. men increased from 17.8 to 22.4. Compared with rates in 1999,
U.S. suicide rates in 2017 were higher for males and females in all age groups from 10
to 74 years. This rise in U.S. suicide rates stands in sharp contrast to the significant de
cline in global suicide rates. Globally, age-standardized suicide rates decreased by
32.7% between 1990 and 2016 (Naghavi 2019). However, the average annual percent
age increase in suicide death rates in the United States accelerated from approximately
1% per year from 1999 through 2006 to 2% per year from 2006 through 2017 (Hede
gaard et al. 2018).
Stigmatization and Misconceptions

Many people find suicide difficult to discuss due to centuries of stigma associated with
this subject. People who have suicidal thoughts or histories of suicidal behavior often
are embarrassed or ashamed to discuss these experiences, fearing that others will think
worse of them. Individuals with suicidal thoughts may report plans to make a suicide
attempt appear to be an unintentional death in order to reduce a sense of embarrass
ment among surviving loved ones. Similarly, people who are concerned about others
often are hesitant or fearful of directly asking about suicidal thoughts or plans. Many
people fear that if they ask, they will be “suggesting” suicide or are concerned that
the person will be insulted, offended, or humiliated.
Decreasing the negative social stigma attached to suicide is imperative. This re
quires that we recognize that suicide is not a “disease” or “psychiatric disorder.” Sui
cide attempts and deaths can be the outcome of multiple medical and psychiatric
disorders as well as the outcome of chronic and acute psychosocial stressors. “Respi
ratory failure” may be the ultimate cause of death in a variety of diseases and can be
recognized as a cause of death even without knowing the underlying diagnosis. Sim
ilarly, suicidal thinking or behavior may be recognized by preceding signs and symp
toms, even if the underlying cause has not been specifically identified.
Thus, addressing the stigma of suicide also requires that we change how we dis
cuss this important subject with our patients and in our social discourse. The Centers
for Disease Control and Prevention (CDC) National Center for Injury Prevention and
Introduction xix
TABLE–1. Centers for Disease Control and Prevention National Center for Injury
Control and Prevention suggested terminology for suicide and self
directed injury
Unacceptable term Suggested replacement
Completed suicide or successful suicide Suicide

Failed attempt or failed suicide Suicide attempt or suicidal self-directed violence
Nonfatal suicide Suicide attempt
Suicidality Suicidal thoughts and suicidal behavior
Suicide gesture, manipulative act, or suicide Nonsuicidal self-directed violence or suicidal
threat self-directed violence
Source. Crosby et al. 2011, p. 23.
TABLE–2. Centers for Disease Control and Prevention suggestions for uniform
terms and definitions
Term Definition
Suicidal ideation Thoughts of engaging in suicide-related behavior

Suicidal intent Evidence (explicit and/or implicit) indicates that at the time of injury the
individual intended to kill him- or herself or wished to die and that the
individual understood the probable consequences of his or her actions
Suicidal plan A thought regarding a self-initiated action that facilitates self-harm
behavior or a suicide attempt, often including an organized manner of
engaging in suicidal behavior such as a description of a time frame and
method
Suicide attempt A nonfatal, self-directed, potentially injurious behavior with any intent to
die as a result of the behavior; may or may not result in injury
Suicide Death caused by self-directed injurious behavior with an intent to die as
a result of the behavior
Source. Crosby et al. 2011, pp. 21, 23, 90
Control examined commonly used terms in regard to suicides. They deemed many of
these, including failed attempt, successful suicide, suicide gesture or threat, and suicidality
unacceptable because they convey negative social judgments, are contradictory, or
are vague and imprecise (see Table 1; Crosby et al. 2011, p. 23).
The CDC reviewers have offered uniform language and definitions to improve
communication and precision about the nature of an individual’s problems with sui
cidal thoughts or behavior (see Table 2). We encourage adoption of the CDC’s termi
nology and have endeavored throughout this volume to use similar nonjudgmental
and precise terms so as to decrease stigmatization associated with suicide. The use of
the word suicide as a verb or the constructions committed suicide or death by suicide are
problematic. Terms such as suicide death, death from suicide, or died from suicide are more
neutral, accurate, and facilitate rather than hinder frank discussion of this serious
public health problem.
Efforts to improve education and public discourse and decrease stigmatization
also require that we directly address and correct widely held misconceptions regard
xx Textbook of Suicide Risk Assessment and Management, Third Edition
ing suicide. For example, many mistakenly believe that people intent on dying from
suicide will find a way to do so, even if a suicide death is averted on one given occa
sion. The fact is that although a history of a suicide attempt is a risk factor for future
suicide, only about 10% of individuals who make a suicide attempt go on to die from
suicide (Barber and Miller 2014). After a suicide attempt, people are more likely to
come to the attention of others and receive mental health treatment, which mitigates
risk of future suicidal thoughts and behavior (Mann et al. 2005). Therefore, engage
ment in appropriate treatment may constitute a lifesaving intervention.
Similarly, the mistaken belief that people considering suicidal behavior will not tell
anyone about their thoughts or plans is common. In fact, contact with mental health
and primary care providers prior to suicide is common (Ahmedani et al. 2014; Luoma
et al. 2002). Thus, each patient contact with a medical or mental health treatment pro
vider provides an opportunity to decrease suicide risk through appropriate assess
ment and intervention.
Assessment of Risk Versus Prediction

A major change in perspective in how to best address suicide is one of the most im
portant developments over past years and is reflected in the chapters of this volume.
Mental health professionals and researchers have shifted from a model of “suicide
prediction” to a model that emphasizes assessment and management of suicide risk.
Psychosocial stressors, cultural factors, and chance circumstances, as well as psychi
atric illness and substance use, may play a significant role in an individual’s suicide
death. Clinicians cannot assess all the multiple and dynamic variables involved in a
suicide death and therefore cannot reliably predict of who will or will not attempt or
die from suicide.
Despite being the tenth leading cause of death in the United States, suicide is a sta
tistically rare event, and therefore the “absolute risk” of suicide death is low. Statisti
cal analysis demonstrates that efforts to predict rare events, such as whether patients
will attempt suicide or engage in a violent act, result in a large number of false posi
tives (Maris 2002; Swanson 2011). The vast majority of people, even those who ex
press active suicidal thoughts, do not die from suicide. In contrast, the assessment of
“relative risk” of suicide is based on the fact that people with mental illness are sig
nificantly more likely to commit suicide than people who do not have mental illness.
Suicide prevention efforts require the assessment of relative risk of death from suicide
based on identifiable suicide risk and protective factors.
SRA and management of suicide risk factors is therefore the key to identification
of suicidal thoughts and behaviors and implementing appropriate treatment inter
ventions. Thorough, systematic, and repeated SRA on a case-by-case basis allows
mental health professionals to identify factors that can be modified to reduce risk, as
sess the efficacy of treatment interventions, and address the unique circumstances
that may increase or decrease a patient’s risk of death from suicide. Some patients
may require immediate psychiatric treatment, such as hospitalization for safety and
initiation of pharmacotherapy to treat psychiatric disorders. Some patients may ben
efit just as much or more from interventions that increase social supports or address
nonmedical needs.
Introduction xxi
Notably, competent suicide risk assessment and management has also become in
creasingly recognized as one of the most significant elements in the legal assessment
of whether adequate care has been rendered to patients who attempt or die from sui
cide. Although the rates of professional claims made against psychiatrists are among
the lowest of any medical specialty, suicide attempts or deaths constitute between
15% and as many as 37% of psychiatric professional negligence claims (Vanderpool
2018). Evidence in these cases requires expert testimony regarding the “standard of
care,” which is generally defined as the degree of attentiveness, caution, and pru
dence that a reasonable physician would exercise under similar circumstances.
Historically, experts have differed on what constitutes the standard of care for as
sessing and responding to suicide risk. Nevertheless, after a review of professional
negligence cases involving suicide, Obegi (2017) identified the following as probable
“expectations of clinical care, as they pertain to SRA, based on the legal concept of the
reasonably careful person” (p. 453).
1. Gathering information from the patient

2. Gathering data from other sources
3. Estimating suicide risk
4. Treatment planning
5. Documentation
6. Reassessing risk at significant clinical junctures, such as changes in the patient’s
circumstances, condition, or treatment
Although no models of performing SRAs have been formally adopted by any pro
fessional organization or training program, all SRA models that have been suggested
as guides for clinicians encompass these six elements.
The Purpose of This Third Edition

This edition has incorporated new perspectives regarding suicide on a variety of lev
els. The medical and social use of destigmatizing and more precise language, for ex
ample, was discussed earlier. In addition, chapter authors have reviewed research
identifying additional suicide risk factors, such as sleep disorders, and their clinical
implications. Topics integral to current issues related to suicide are also reviewed, in
cluding nonfatal, self-injurious behavior; physician-assisted suicide; and teaching
suicide risk assessment and management during psychiatric residency. This edition
also examines the increased rates of suicide among specific populations, including
children, adolescents, and college students, and makes recommendations regarding
suicide risk management in these populations.
We believe that psychiatrists at all level of practice, but especially those in train
ing, will find much information in this volume of use. The material reviewed in this
text is essential for those in mental health and primary care training programs. The
information reviewed here also will be of value to other mental health professionals,
including psychologists, advance practice nurses, psychiatric nurse clinicians, social
workers, licensed professional counselors, and primary care physicians. Most impor
tantly, we hope this volume will provide information and assistance to practicing cli
xxii Textbook of Suicide Risk Assessment and Management, Third Edition
nicians and suicide prevention programs working with those who struggle with
suicidal thoughts and behaviors.
Acknowledgments
We would like to thank the chapter authors for their contributions to this volume.
Without their diligence and expertise, this edition would not be possible. We also
thank American Psychiatric Association Publishing for giving us the opportunity to
edit this edition of this essential text and to contribute to education and training of
mental health and medical professionals. We hope that focusing on suicide risk as
sessment and management will result in a decrease in the rates of death from suicide
in the United States and reverse what has been a deeply disturbing trend.
L.H.G.: Thanks to my family for their patience and support. I also wish to ac
knowledge my deep gratitude to and respect for Richard Frierson, friend and col
league, for the hard work of coediting this volume. His collaboration made this
challenging project more enjoyable as well as more manageable.
R.L.F.: Thanks to Liza Gold for her encouragement during this process, her excel
lent editing skills, and her understanding of my very busy year. Also, thanks to col
leagues, past and present, who make my work enjoyable.
References
Accreditation Council for Graduate Medical Education: ACGME Program Requirements for
Graduate Medical Education in Psychiatry. Chicago, IL, Accreditation Council for Gradu
ate Medical Education, 2019. Available at: https://www.acgme.org/Portals/0/PFAssets/
ProgramRequirements/400_Psychiatry_2019.pdf?ver=2019–06–19–091051–927. Accessed
August 3, 2019.
Ahmedani BK, Simon GE, Stewart C, et al: Health care contacts in the year before suicide death.
J Gen Intern Med 29(6):870–877, 2014 24567199
Barber CW, Miller MJ: Reducing a suicidal person’s access to lethal means of suicide: a research
agenda. Am J Prev Med 47(3 suppl 2):S264–S272, 2014 25145749
Centers for Disease Control and Prevention: Injuries (website). Atlanta, GA, Centers for Dis
ease Control and Prevention, 2017a. Available at: https://www.cdc.gov/nchs/fastats/
injuries.htm. Accessed August 3, 2019.
Centers for Disease Control and Prevention: Suicide (website). Atlanta, GA, Centers for Disease
Control and Prevention, 2017b. Available at: https://www.nimh.nih.gov/health/statistics/
suicide.shtml. Accessed August 3, 2019.
Cramer RJ, Johnson SM, McLaughlin J, et al: Suicide risk assessment training for psychology
doctoral programs: core competencies and a framework for training. Train Educ Prof Psy
chol 7(1):1–11, 2013 24672588
Crosby AE, Ortega L, Melanson C: Self-Directed Violence Surveillance: Uniform Definitions
and Recommended Data Elements, Version 1.0. Atlanta, GA, Centers for Disease Control
and Prevention, National Center for Injury Prevention and Control, 2011
Graham RD, Rudd MD, Bryan CJ: Primary care providers’ views regarding assessing and treat
ing suicidal patients. Suicide Life Threat Behav 41(6):614–623, 2011 22145822
Hedegaard H, Curtin SC, Warner M: Suicide mortality in the United States, 1999–2017. NCHS
Data Brief No 330. Hyattsville, MD, National Center for Health Statistics, 2018
Introduction xxiii
Jacobs DG, Baldessarini RJ, Conwell Y, et al: Practice Guideline for the Assessment and Treat
ment of Patients with Suicidal Behaviors. Arlington, VA, American Psychiatric Associa
tion, 2003
Jacobson JD, Osteen P, Jones A, et al: Evaluation of the recognizing and responding to suicide
risk training. Suicide Life Threat Behav 42(5):471–485, 2012 22924960
Luoma JB, Martin CE, Pearson JL: Contact with mental health and primary care providers be
fore suicide: a review of the evidence. Am J Psychiatry 159(6):909–916, 2002 12042175
Mann JJ, Apter A, Bertolote J, et al: Suicide prevention strategies: a systematic review. JAMA
294(16):2064–2074, 2005 16249421
Maris RW: Suicide. Lancet 360(9329):319–326, 2002 12147388
McNiel DE, Fordwood SR, Weaver CM, et al: Effects of training on suicide risk assessment. Psy
chiatr Serv 59(12):1462–1465, 2008 19033175
Naghavi M: Global, regional, and national burden of suicide mortality 1990 to 2016: systemic
analysis for the Global Burden of Disease Study 2016. BMJ 364:194, 2019
Obegi JH: Probable standards of care for suicide risk assessment. J Am Acad Psychiatry Law
45(4):452–459, 2017 29282236
Parra-Uribe I, Blasco-Fontecilla H, Garcia-Parés G, et al: Risk of re-attempts and suicide death
after a suicide attempt: a survival analysis. BMC Psychiatry 17(1):163, 2017 28472923
Pisani AR, Cross WF, Gould M: The assessment and management of suicide risk: state of work
shop education. Suicide Life Threat Behav 41(3):255–276, 2011 21477093
Rudd MD: Core competencies, warning signs, and a framework for suicide risk assessment in
clinical practice, in The Oxford Handbook of Suicide and Self-Injury. Edited by Nock MK.
New York, Oxford University Press, 2014, 323–336
Schmitz WM, Allen MH, Feldman BN, et al: Preventing suicide through improved training in
suicide risk assessment and care: an American Association of Suicidology task force report
addressing serious gaps in U.S. mental health training. Suicide Life Threat Behav
42(3):292–304, 2012 22494118
Silverman MM: Suicide risk assessment and suicide risk formulation: essential components of
the therapeutic risk management model. J Psychiatr Pract 20(4):373–378, 2014 25226200
Simon RI: Suicide risk assessment: gateway to treatment and management, in Textbook of Sui
cide Assessment and Management, 2nd Edition. Edited by Simon RI, Hales RE. Washing
ton, DC, American Psychiatric Publishing, 2012, pp 3–28
Swanson JW: Explaining rare acts of violence: the limits of evidence from population research.
Psychiatr Serv 62(11):1369–1371, 2011 22211218
Vanderpool D: Professional liability in psychiatric practice, in Textbook of Forensic Psychiatry,
3rd Edition. Edited by Gold LH, Frierson RL. Washington, DC, American Psychiatric As
sociation Publishing, 2018, pp 169–184
PART I
and Treatment
CHAPTER 1

Liza H. Gold, M.D.
Death from suicide is a significant public health issue strongly associated with psy
chiatric illness and substance use disorders. Assessing suicide risk is a necessary clinical
skill in all mental health and primary care settings and a core competency in medical
student education and psychiatric residency training. To date, all comprehensive
approaches to suicide prevention have included the training of health professionals as
a critical component of their strategies (Schmitz et al. 2012). Physician education in sui
cide risk assessment and management begins with training in suicide risk assessment
(SRA). SRA is the gateway to mental health treatment, one of only two interventions
empirically demonstrated to reduce suicide mortality (Mann et al. 2005).
SRA is a complex and challenging clinical task. Suicide is not a diagnosis but a con
sequence of behavior associated with multiple psychiatric diagnoses as well as non
psychiatric psychosocial circumstance. Moreover, patients with similar diagnoses are
at varying degrees of risk for death from suicide, and level of risk can change rapidly
and often without notice. Nevertheless, SRA should be routinely conducted with all
patients, not just those already identified as being at risk.
Case Example
Mr. Nelson, a 68-year-old white male, was referred to Dr. Smith, a psychiatrist, because
he was refusing low-risk surgery for removal of a benign tumor, stating, “Why bother?
It will all be over soon anyway.” At intake, Mr. Nelson told Dr. Smith that his wife of 35
years had died 2 years prior. Since then, Mr. Nelson has had increasing financial prob
lems. He was living alone in the home he had shared with his wife but had stopped do
ing routine household chores. Mr. Nelson had three adult children but reported that
since his wife died, “I don’t talk to them much.” He also reported he was drinking al
cohol every night “because I can’t sleep.”
Dr. Smith asked Mr. Nelson whether he had thoughts about suicide. Mr. Nelson ac
knowledged considering killing himself, stating that in the past few weeks, while
drinking, he had been handling his gun, loading and unloading it multiple times. Mr.
Nelson stated that he has not shot himself because “I know my wife would be mad.”
However, he stated that he does not feel that he has any reason to go on living, and he
3
4 Textbook of Suicide Risk Assessment and Management, Third Edition
had hoped his tumor meant he had cancer so he would have a “good reason to kill my
self—you know, a reason my wife and kids would understand.”
Dr. Smith called Mr. Nelson’s son, who reported that his father had become with
drawn and isolative and that his family was “very worried about him.” The son asked
Dr. Smith, “Do you think he’s going to kill himself?” Dr. Smith candidly told Mr. Nel
son’s son that she could not predict whether Mr. Nelson would actually try to kill him
self but that he was at high risk of death from suicide. Dr. Smith recommended inpatient
hospitalization for Mr. Nelson's safety and to begin treatment. After discussing Dr.
Smith's recommendation with his son, Mr. Nelson agreed to a voluntary admission.
Suicide Risk Assessment: Prevention, Not Prediction

Efforts to predict whether patients will attempt suicide result in a large number of
false-positives and false-negatives (Simon 2012b; Swanson 2011). The “absolute risk”
that any individual will die from suicide is low because the vast majority of people,
even those who express active suicidal thoughts, do not die from suicide. Despite being
the tenth leading cause of death in the United States, suicide is a statistically rare
event. In 2017, the overall national rate of suicide was 14.5 deaths per 100,000 people
(Centers for Disease Control and Prevention 2019). Suicide prevention therefore fo
cuses on the assessment of “relative risk” of death from suicide based on consider
ation of known suicide risk and protective factors. In contrast to absolute risk, the
assessment of relative risk is based on the fact that people with mental illness are sig
nificantly more likely to die from suicide than people who do not have mental illness
(Swanson 2011).
Methodology
Some mental health professionals rely on the clinical interview alone to assess suicide
risk. Others rely on structured or semistructured checklists or patient self-surveys.
The use of any of these methods does not, of itself, constitute an adequate SRA. Un
aided and unstructured clinical judgment is central in identifying and assigning
weight to the risk and protective factors identified through systematic assessment,
but it is highly subject to error when relied on as the sole SRA methodology (Berman
and Silverman 2014; Simon 2012b). In addition, patients at risk of death from suicide,
particularly individuals who are intent upon dying, may deny or conceal a history of
suicidal thoughts or behavior (Nock et al. 2008; Rudd 2014). For example, patients
who made suicide attempts within 60 days of a health care visit reported they denied
suicidal ideation because of fear of stigma, “clinician’s overreaction,” or loss of auton
omy (Richards et al. 2019).
Similarly, use of any checklist alone does not constitute an adequate SRA (Simon
2012a, 2012b). Many suicide risk factors are not simply present or absent but may
vary in degrees of severity. Some factors may contribute to risk in some individuals
but not in others or may be relevant only when they occur in combination with par
ticular psychosocial stressors (Jacobs et al. 2003).
General Principles
Clinicians can only determine the level of relative risk of death from suicide, as Dr.
Smith in the case example informed Mr. Nelson’s son. SRA is a process of semistruc
Suicide Risk Assessment 5
tured assessment that assigns a level of risk based on systematic identification and
prioritization of evidence-based acute or short-term risk factors, chronic or long-term
risk factors, and protective factors (Simon 2012b). Higher versus lower levels of per
ceived risk carry greater imperatives for aggressive treatment planning, triage, and
intervention (Berman and Silverman 2014).
A suicide risk factor is defined as a factor empirically demonstrated to correlate with
suicide, regardless of when it first becomes present. Short-term risk factors, such as
panic attacks, agitated depression, and insomnia, are those found prospectively and
are statistically significant within 1 year of assessment. Long-term risk factors, derived
from association with deaths from suicide 2–10 years after assessment, include suicidal
ideation, severe hopelessness, and prior attempts. The presence of chronic or long-term
risk factors establishes lifetime vulnerability to suicide risk (Berman and Silverman
2014; Rudd 2014). Protective factors are those that decrease risk of suicide, such as
close, supportive family relationships, and identification of these is also integral to a
thorough SRA.
Clinicians may include warning signs as a separate category of risk factors. These may
overlap to some degree with short-term risk factors but are distinct in that they provide
observable markers consistent with potentially increased intent. The presence of one or
more warning signs is indicative of increased suicide risk in the context of lifetime vulner
ability and may be the earliest detectable indications of acute heightened risk for death
from suicide (Berman and Silverman 2014; Rudd 2014). Additionally, clinicians are
more likely to assign a high-risk designation once objective evidence of suicide intent
is identified, such as preparation and rehearsal behaviors (Rudd 2014).
No single risk factor or warning sign is pathognomonic for suicide. In addition, a
single suicide risk factor, or even combination of risk factors, does not have the statis
tical significance on which to base an overall risk assessment due to the infrequency
(i.e., low absolute risk) of suicide (Jacobs et al. 2003; Simon 2012b). The assessment of
overall suicide risk involves an understanding of how risk factors interact and con
tribute to a heightened or lowered risk of suicide (Berman and Silverman 2014).
Suicidal ideation and planning are significant risk factors for suicide. When assessing
suicidal ideation, clinicians should consider specific content, intensity, duration, and prior
episodes (Berman and Silverman 2014; Rudd 2014). Fleeting, nonspecific suicidal
thoughts with no associated subjective or objective intent should be investigated because
they may indicate acute distress that might need to be addressed. Nevertheless, isolated,
nonspecific thoughts of suicide typically are not evidence of escalation of risk of death
from suicide. Reduced duration of suicidal thoughts frequently translates to reduced
specificity, less severity, and lower intent, along with lower overall risk (Rudd 2014).
However, the presence or absence of suicidal thinking is not a particularly good
indicator of escalating suicide risk, especially in individuals who have made multiple
attempts and in those with chronic suicidal ideation (Rudd 2014; Simon 2012b). Many
suicide attempts demonstrate a strong component of impulsivity. Most studies of im
pulsivity and suicide have found an absence of proximal planning or abruptness of
attempt in more than 50% of cases (Rimkeviciene et al. 2015). Seventy-five percent of
suicide attempts occur within 3 hours or less from the time of initial suicidal ideation,
planning, or the decision to make an attempt. The length of time between first
thoughts and an attempt has been found to be as little as a few minutes to a few hours
(Ilgen et al. 2008; Yip et al. 2012).
Mr. Nelson, in the case example, demonstrated risk factors that—when taken to
gether—led Dr. Smith to conclude that he was at high risk of suicide. These included
symptoms of depression, suicidal thoughts, a plan, access to highly lethal means (a
gun), alcohol abuse, and insomnia, all with onset in the past 2 years since the loss of
his wife. In addition, Mr. Nelson’s reason for not killing himself was not rational, in
dicating the possibility of cognitive impairment or delusional thinking. Other risk
factors included financial problems and social withdrawal. Mr. Nelson’s demo
graphic risk factors included his sex (male), his ethnicity (white), and his age (over
65). Dr. Smith could not identify any significant protective factors. Finally, Dr. Smith
noted Mr. Nelson’s warning signs of preparation and rehearsal with his gun.
Suicide Risk Assessment and Treatment

Systematic risk assessment requires clinicians to gather essential information from
multiple sources and not just rely on information based on patients' self-report. Col
lateral information may be a key element in SRA, particularly when a patient denies
ideation, intent, or plans. Family members should be consulted if possible, as Dr.
Smith did in Mr. Nelson’s case, because family may be aware of changes in behavior
or warning signs that the patient does not report (Simon 2012b). Additional collateral
information may be obtained from medical records, the patient’s medical and mental
health providers, friends, and possibly other sources, such as police records (Silver
man and Berman 2014; Simon 2012b; Table 1–1).
Clinicians typically use a dimensional scale of low, moderate, or high to describe
suicide risk (Berman and Silverman 2014; Rudd 2014; Simon 2012b). As a general rule,
as symptom severity and complexity increase, so does suicide risk, particularly if dis
tinct warning signs also are present. Low risk is characterized by mild psychiatric
symptoms with no associated suicidal intent or features. Moderate risk emerges as
symptoms escalate, warning signs start to emerge, and evidence of subjective intent
is identified. Dr. Smith’s assessment of Mr. Nelson identified four essential elements
that characterize high risk, including serious psychiatric symptoms and alcohol use,
the presence of active intent (subjective or objective), the presence of warning signs,
and limited protective factors (Rudd 2014).
Importantly, SRA should be an ongoing process, not a singular event. Suicide intent
can increase with the accumulation of stressors or decrease as effective interventions
are implemented. The accuracy of any SRA therefore decreases over time as circum
stances and clinical risk factors change. Consequently, SRA needs to be repeated ac
cording to the clinical needs of the patient, particularly when a treatment decision that
changes levels of safety or structure, such as discharge from inpatient treatment, is
considered (Jacobs et al. 2003; Silverman and Berman 2014; Simon 2012b).
Treatment: Static and Dynamic Risk Factors

Systematic SRA is critical to clinical decision making, including safety planning and
management; triage decisions; treatment planning, especially regarding voluntary or
involuntary hospitalization; and overall risk management (Silverman and Berman
2014; Simon 2012b). Higher versus lower levels of perceived risk carry greater imper
atives for aggressive treatment planning, triage, and intervention (Berman and Silver
man 2014). Dr. Smith’s assessment of Mr. Nelson’s high risk indicated that inpatient
treatment was needed both for his safety and to initiate treatment.
TABLE 1–1. Suicide risk assessment: approach to initial data gathering
1. Identify distinctive individual suicide risk factors

2. Identify acute suicide risk factors
3. Identify protective factors
4. Evaluate medical history, including laboratory data if available
5. Obtain information from other clinical care providers such as primary care providers
6. Interview patient’s significant others
7. Speak with current or prior mental health treatment providers, including treatment
team if inpatient
8. Review patient’s current and prior hospital records
Source. Simon 2012a.
Decisions regarding specific treatment interventions rely on recognition of dy

namic as opposed to static risk factors. Static risk factors are those that cannot be mod
ified. Although static factors such as demographic characteristics, family history, or
history of suicide attempts are important to identify, they cannot be the focus of clin
ical intervention. Mr. Nelson’s static risk factors include his age, sex, and ethnicity.
Awareness of the risk associated with these may lead clinicians to weigh other risk
factors more heavily, but static risk factors themselves cannot be changed.
In contrast, dynamic risk factors are those that can be modified and thus should be
identified as early as possible and treated aggressively. For example, anxiety, depres
sion, insomnia, and psychosis may respond rapidly to medications as well as psycho
social interventions. In the case example, after admission to an inpatient unit, Mr.
Nelson was prescribed an antidepressant that mitigated many of his depressive symp
toms, including insomnia. Mr. Nelson also began attending Alcoholics Anonymous
meetings, which he found helpful and which provided significant social support.
Clinicians should also identify and enhance, when possible, protective factors. For
instance, psychosocial interventions can help a patient mobilize available social sup
ports (Jacobs et al. 2003; Rudd 2014; Simon 2012b). In the case of Mr. Nelson, treat
ment providers were able to help him reconnect with his children, who became his
most significant source of social support.
Structured Assessment of Suicide Risk Factors

Each patient contact is an opportunity to decrease suicide risk through appropriate
assessment and intervention. Unfortunately, formal, systematic training of most men
tal health professionals in the assessment and management of suicidal patients is lim
ited. Many mental health professionals appear to lack the requisite training and skills
to appropriately assess for suicide risk (Jacobson et al. 2012; Schmitz et al. 2012). The
lack of formal training is in part due to the fact that no guideline, methodology, or
standard assessment tool has been formally endorsed for conducting SRAs (see
Chapter 31, “Teaching Suicide Risk Assessment in Psychiatric Residency Training”).
Nevertheless, suggested frameworks for SRA are generally consistent in their rec
ommended methodology and typically combine semistructured tools, self-report sur
veys, and the clinical interview. Semistructured screening instruments, such as the
Columbia Suicide Severity Rating Scale (C-SSRS; Interian et al. 2018; Youngstrom et
al. 2015), the Suicide Tracking Scale, and the Sheehan Suicidality Tracking Scale
(Youngstrom et al. 2015) complement and improve routine clinical assessments and
can provide support and corroboration for a well-conducted clinical SRA (Silverman
and Berman 2014; Simon 2012b). They also increase opportunities for capturing sig
nificant information. For example, use of self-report measures, such as the Beck De
pression Inventory (Green et al. 2015), in addition to a structured clinical interview,
provides patients who have difficulty verbalizing suicidal ideation with another op
tion to report this information (Silverman and Berman 2014).
SRAs should include inquiries about and review of demographic, short-term, and
long-term risk factors as well as the individual patient’s unique risk and protective factors
(Simon 2012b). Clinicians should routinely obtain information regarding previous sui
cidal behavior, current suicidal thoughts or plans, life stressors and adverse events, the
presence of psychiatric symptoms, substance use, access to highly lethal methods such as
firearms, and protective factors. One SRA model (Rudd 2014) identifies seven catego
ries of risk factors, or domains, with 24 different individual risk factors, as well as a
domain for suicide warning signs and a domain for protective factors (Table 1–2).
Nevertheless, semistructured checklists alone also are not effective SRA methodol
ogies (Jacobs et al. 2003; Simon 2012b). Checklists are overly sensitive, lack specificity,
and cannot encompass all the relevant risk or protective factors for a given patient.
None have been tested for reliability and validity (Silverman and Berman 2014; Si
mon 2012b). The key to SRA is conducting a comprehensive systematic assessment;
the model presented here and other similar models should be considered an aid or
guide to systematic assessment.
Suicide Risk Factors: An Overview

A detailed discussion of all risk and protective factors and the strength of the empir
ical evidence behind them is beyond the scope of this discussion. Psychiatric illness
and substance use are the strongest risk factors for death from suicide (Ilgen et al.
2008; Nock et al. 2008). The following is a brief discussion of these and other highly
significant risk factors. The association of death from suicide with specific diagnoses
is discussed in subsequent chapters.
Psychiatric Disorders
As many as 90%–95% of suicide victims have a diagnosable psychiatric disorder at
the time of death, and those who die from suicide are more likely to meet criteria for
more than one psychiatric diagnosis (Arsenault-Lapierre et al. 2004; Nock et al. 2008).
Analysis of the National Comorbidity Study data found that 82% of individuals who
reported suicidal ideation, 95% of individuals who reported making suicide plans,
and 88% of individuals who reported making suicide attempts met criteria for one or
more DSM disorders (Kessler et al. 2005). Affective, substance-related, personality,
and psychotic disorders account for most of the diagnoses among individuals who
die from suicide. Of these, mood disorders, particularly depression, present high risk,
followed closely by alcohol use disorders, with highest risk in those with both affec
tive disorders and alcohol use disorders (Arsenault-Lapierre et al. 2004).
TABLE 1–2. Sample suicide risk assessment checklist
Sample checklist: domain Suicide risk assessment factors: specific risk
1. Predisposition to suicidal History of psychiatric diagnoses (including substance

behavior abuse): higher risk with recurrent disorders,
comorbidity, chronicity
History of suicidal behavior: higher risk with previous
attempts, high lethality; considered chronic risk if
two or more attempts have been made
Recent discharge from inpatient psychiatric treatment;
high risk in first year after discharge, higher in first
month after discharge, highest risk during first week
after discharge
Demographic considerations: age, sex, ethnicity
History of sexual, physical, or emotional abuse
2. Identifiable precipitants or Financial
stressors (most perceived as a Interpersonal relationship(s) and relationship
loss) instability (loss of social support)
Nursing home placement
Professional identity, retirement
Acute or chronic health problems (can encompass loss
of independence, autonomy, or function)
3. Symptomatic presentation Depressive symptoms: highest risk associated with
comorbid anxiety and substance abuse symptoms
In elderly, depression may present as misuse of
medications, unexplained accidents, or intentional
decreased intake
Bipolar disorder: highest risk early in course of disorder
Anxiety, especially acute agitation
Schizophrenia, especially in time periods following
active phases
Borderline and antisocial personality features
4. Hopelessness Severity
Duration
5. Nature of suicidal thinking and Current ideation: frequency, intensity, and duration
behaviors Presence of suicidal plan, increased risk with
specificity
Availability of means (consider multiple methods)
Access to (not just ownership of) firearms
Lethality of means including both medical and
perceived lethality
Active suicidal behaviors including preparation and
rehearsal behaviors
Suicide intent with subjective and objective markers
(warning signs)
TABLE 1–2. Sample suicide risk assessment checklist (continued)
Sample checklist: domain Suicide risk assessment factors: specific risk
6. Previous suicide attempts (and Frequency

nonsuicidal self-injury) Perceived lethality and outcome
Opportunity for rescue and help seeking
Preparatory behaviors (including rehearsals)
Reaction to previous attempts (feelings about survival
and lessons learned)
7. Impulsivity and self-control Subjective self-control
Objective control (e.g., substance abuse, impulsive
behaviors, aggression)
8. Presence of suicide warning signs Active suicidal thinking
Preparation and rehearsal behavior
Anger
Recklessness, impulsivity, dramatic mood changes
Anxiety and agitation
Feeling trapped
No reasons for living, no purpose in life
Increased alcohol or substance abuse
9. Protective factors Presence and accessibility of social support
Problem-solving skills
Active participation in treatment
Presence of hopefulness
Children/Grandchildren present in the home
Religious commitment
Life satisfaction
Intact reality testing
Fear of social disapproval
Fear of suicide or death
Source. Adapted from Rudd 2014.
Alcohol and Drug Use

Suicide is one of the leading types of injury mortality linked with alcohol consump
tion (Conner et al. 2014). Individuals with a moderate to severe alcohol use disorder
who come to clinical attention are at approximately nine times higher risk of death
from suicide compared with the general population. Use of alcohol in the hours pre
ceding suicidal behavior, regardless of the presence of an alcohol use disorder, is also
highly prevalent and is a powerful independent risk factor beyond the risk conferred
by chronic alcohol use (Kaplan et al. 2013). An analysis of the National Violent Death
Reporting System data found that alcohol was present at the time of death in one
third of suicides by firearms, hangings, and poisonings, which constitute more than
90% of deaths from suicide in the United States. Moreover, the mean blood alcohol
concentration levels in those who died from suicide exceeded 80 mg/dL, the legal limit
for intoxication (Conner et al. 2014).
The association between other substance use disorders and suicidal behavior is as
compelling as the association between alcohol use disorder and suicide. One meta
analysis (Poorolajal et al. 2016) found that individuals who abuse drugs had in
creased risk of suicidal ideation, suicide attempts, and suicide as compared to drug
nonusers. Data from the 2014 National Survey of Drug Use and Health (Ashrafioun
et al. 2017) indicated that prescription opioid misuse was significantly associated
with suicidal ideation, suicide planning, and suicide attempts in those who misuse
opioids, regardless of frequency of misuse.
Individuals with substance use disorders often enter treatment with depressive
symptoms and a number of severe stressors, such as relationship loss, job loss, and
health and financial problems. These may be the precipitants for seeking treatment,
but these circumstances also put them at higher risk for suicidal behavior. Approxi
mately 40% of patients seeking treatment in substance abuse programs for moderate
to severe opiate use disorder and cocaine use disorder report a history of suicide at
tempts (Yuodelis-Flores and Ries 2015). In one study, 58% of those with polysubstance
dependence (DSM-IV; American Psychiatric Association 1994) seeking treatment re
ported lifetime suicide attempts compared to 38% of those who were only alcohol de
pendent (Landheim et al. 2006).
Co-occurring psychiatric disorders and substance use disorders appear to have the
strongest association with increased risk of suicide. In one study, the comorbidity of
major depressive disorder and alcohol use disorder (severe) increased the risk of sui
cide by 4.5-fold in persons aged 20 years and 83-fold in those age 50 years (Conner et
al. 2003). Higher rates of suicidal thinking and behavior have also been found in in
dividuals with substance use disorders and comorbid schizophrenia, posttraumatic
stress disorder, and borderline personality disorder (Yuodelis-Flores and Ries 2015).
Suicidal Ideation, Behavior, and Attempts

Suicidal ideation and related behaviors, including warning signs and intent, are also
some of the most significant suicide risk factors. In the National Comorbidity Survey,
Kessler et al. (1999) found that approximately 90% of unplanned suicide attempts and
60% of planned first attempts occurred within 1 year of the onset of suicidal ideation.
The probability of transitioning from suicidal ideation to suicidal plan was 34%; the
probability of transition from a plan to an attempt was 72%. A cross-national study
(Nock et al. 2008) found that the lifetime prevalences of suicidal ideation, suicide
plans, and suicide attempts were 9.2%, 3.1%, and 2.7%, respectively.
A history of having made a previous suicide attempt is also widely recognized as
a risk factor for death from suicide. Studies of rates of death from suicide associated
with a history of suicide attempt may significantly underestimate the strength of this
association (Bostwick et al. 2016). Nevertheless, as many as 20%–25% of individuals
who died from suicide had made attempts in the year prior to death, with risk signifi
cantly higher for men than for women (Cooper et al. 2005). Parra-Uribe et al. (2017)
found that within 1 year of a first-time suicide attempt, 20.1% of individuals at
tempted suicide at least once more and 1.2% died from suicide. Younger age, the
presence of a personality disorder, and alcohol use disorder were risk factors for reat
tempting; alcohol use and older age were risk factors for death from suicide.
Adverse Life Events

Major interpersonal stressful life events may increase suicide risk, particularly among
adults with alcohol use disorders, other compromised coping skills, and psychiatric or
psychological vulnerabilities (Nock et al. 2008). In vulnerable individuals, an adverse
event may lead to a suicide attempt within a relatively short period of time. One meta
analysis (Liu and Miller 2014) found evidence for a consistent association between
negative life events and suicidal ideation and behavior. Specifically, support for an as
sociation with life stressors was most consistent for death from suicide, followed by
suicide attempts and, finally, suicidal ideation. Owens et al. (2003) found that half of
all suicide decedents had experienced at least one adverse life event in their final
month of life, most commonly concerning relationships, money, and work.
Exposure to a wide range of past and current adverse life events increases an indi
vidual’s vulnerability to suicidal behavior (Pompili et al. 2011). A history of stressful
life events, such as parental or family discord, impaired or neglectful parenting, and
physical or sexual abuse during childhood have all been linked to suicide attempts
and deaths from suicide. Examples of current life stressors that may precipitate sui
cidal thoughts and behavior in vulnerable individuals include loss of a significant re
lationship, interpersonal conflicts, financial or occupational problems, involvement
in legal or disciplinary problems, or perceived public shame or humiliation.
Transient personal crises can create considerable emotional distress with intense
negative emotions, such as anger, rage, shame, and guilt. These may arise quickly and
in a crisis situation can lead to an unplanned suicide attempt (Rimkeviciene et al.
2015), particularly in individuals with a history of chronic, intermittent suicidal ide
ation and after recent alcohol consumption (Powell et al. 2001). Suicidal ideation
among impulsive attempters may be more fleeting and temporary than that experi
enced by persons with chronic depression. Often, as the acute phase of a crisis passes,
the urge to die from suicide decreases (Miller et al. 2012; Yip et al. 2012).
Protective Factors
Although less research is available identifying factors that protect individuals from
suicide compared to research regarding suicide risk factors, protective factors are
critically important in decreasing the probability of a fatal outcome. Like risk fac
tors, protective factors vary with the distinctive clinical presentation of the individ
ual patient (Simon 2012b). Arguably, the most important protective factor is
accessible and available family or other social supports. The ability to engage in
treatment is also a strong protective factor. Additional protective factors include
feelings of responsibility to family, child-related concerns, strong religious beliefs,
and cultural sanctions against suicide (Nock et al. 2008; Simon 2012b). Nevertheless,
in any individual, a delicate balance may exist between suicide risk and protective
factors, and acute high suicide risk may nullify protective factors (Berman and Sil
verman 2014; Simon 2012b).
The case example of Mr. Nelson demonstrated some of the most serious risk factors
for suicide. Fortunately, a thorough assessment and timely treatment interventions
were able to significantly decrease his short-term risk of suicide. Mr. Nelson benefited
from inpatient admission to maintain his safety and initiate treatment with medica
tion. Equally important, Mr. Nelson’s treatment added and enhanced protective fac
tors, which hopefully would continue to keep Mr. Nelson’s future risk of death from
suicide low. These included continuing outpatient treatment with medication and
regular SRA; alcohol abstinence and increased social support through referral to Al
coholics Anonymous; and closer and more supportive relationships with his adult
children and their families.
Conclusion
Mental health treatment has been demonstrated to decrease suicide mortality; SRA is
the access point to mental health treatment. Thorough SRAs, repeated over time and
at critical points in patients’ treatment, will inform decisions regarding treatment and
safety interventions. Each patient has unique risk and protective factors that must be
considered in assessing an overall level of risk of death from suicide. Clinicians are
less likely to overlook important factors that increase or decrease the risk of suicide if
they conduct a systematic assessment that utilizes the clinical interview, patient self
report, a structured or semistructured instrument that can be adapted to each pa
tient’s circumstances, and information gathered from multiple sources.
Key Points
• Clinicians cannot predict death from suicide; only the risk of death from suicide
can be assessed.
• Clinicians cannot rely on patient self-report or clinical judgment alone to de
termine suicide risk. Patients may not report suicidal ideation or behavior,
and clinical judgment is highly subject to error.
• Suicide risk assessments (SRAs) require the use of a combination of semi
structured instruments, clinical interview, and patient report.
• Data collection for SRAs should include collateral sources, medical records,
and psychiatric history.
• Clinicians should consider aggressive clinical intervention in patients who
present with high risk for suicide, particularly patients with combinations of
risk factors highly associated with death from suicide.
• Psychiatric disorders, substance use, and a history of suicidal ideation, behav
ior, or attempts are some of the strongest risk factors for death from suicide.
• Treatment should address dynamic risk factors; the higher the level of risk as
sessed, the more imperative the need for treatment and, possibly, the need
for inpatient hospitalization to maintain patient safety.
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition. Washington, DC, American Psychiatric Association, 1994
Arsenault-Lapierre G, Kim C, Turecki G: Psychiatric diagnoses in 3275 suicides: a meta-analysis.
BMC Psychiatry 4:37, 2004 15527502
Ashrafioun L, Bishop TM, Conner KR, et al: Frequency of prescription opioid misuse and sui
cidal ideation, planning, and attempts. J Psychiatr Res 92:1–7, 2017 28364579
Berman AL, Silverman MM: Suicide risk assessment and risk formulation, part II: suicide risk
formulation and the determination of levels of risk. Suicide Life Threat Behav 44(4):432–
443, 2014 24286521
Bostwick JM, Pabbati C, Geske JR, et al: Suicide attempt as a risk factor for completed suicide:
even more lethal than we knew. Am J Psychiatry 173(11):1094–1100, 2016 27523496
Centers for Disease Control and Prevention: Injury Prevention and Control: Data and Statistics
2019. Atlanta, GA, Centers for Disease Control and Prevention, 2019. Available at:
https://www.cdc.gov/injury/wisqars/index.html. Accessed April 19, 2019.
Conner KR, Beautrais AL, Conwell Y: Moderators of the relationship between alcohol depen
dence and suicide and medically serious suicide attempts: analyses of Canterbury Suicide
Project data. Alcohol Clin Exp Res 27(7):1156–1161, 2003 12878922
Conner KR, Huguet N, Caetano R, et al: Acute use of alcohol and methods of suicide in a US
national sample. Am J Public Health 104(1):171–178, 2014 23678938
Cooper J, Kapur N, Webb R, et al: Suicide after deliberate self-harm: a 4-year cohort study. Am
J Psychiatry 162(2):297–303, 2005 15677594
Green KL, Brown GK, Jager-Hyman S, et al: The predictive validity of the Beck Depression In
ventory suicide item. J Clin Psychiatry 76(12):1683–1686, 2015 26717528
Ilgen MA, Zivin K, McCammon RJ, et al: Mental illness, previous suicidality, and access to guns
in the United States. Psychiatr Serv 59(2):198–200, 2008 18245165
Interian A, Chesin M, Kline A, et al: Use of the Columbia-Suicide Severity Rating Scale (C-
SSRS) to classify suicidal behaviors. Arch Suicide Res 22(2):278–294, 2018 28598723
Jacobs DG, Baldessarini RJ, Conwell Y, et al: Practice Guideline for the Assessment and Treat
ment of Patients With Suicidal Behaviors. Arlington, VA, American Psychiatric Associa
tion, 2003. Available at: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_
guidelines/guidelines/suicide.pdf. Accessed April 22, 2019.
Jacobson JM, Osteen P, Jones A, et al: Evaluation of the recognizing and responding to suicide
risk training. Suicide Life Threat Behav 42(5):471–485, 2012 22924960
Kaplan MS, McFarland BH, Huguet N, et al: Acute alcohol intoxication and suicide: a gender
stratified analysis of the National Violent Death Reporting System. Inj Prev 19(1):38–43,
2013 22627777
Kessler RC, Berglund P, Borges G, et al: Trends in suicide ideation, plans, gestures, and at
tempts in the United States, 1990–1992 to 2001–2003. JAMA 293(20):2487–2495, 2005
15914749
Kessler RC, Borges G, Walters EE: Prevalence of and risk factors for lifetime suicide attempts in
the National Comorbidity Survey. Arch Gen Psychiatry 56(7):617–626, 1999 10401507
Landheim AS, Bakken K, Vaglum P: What characterizes substance abusers who commit suicide
attempts? Factors related to Axis I disorders and patterns of substance use disorders. A
study of treatment-seeking substance abusers in Norway. Eur Addict Res 12(2):102–108,
2006 16543746
Liu RT, Miller I: Life events and suicidal ideation and behavior: a systematic review. Clin Psy
chol Rev 34(3):181–192, 2014 24534642
Mann JJ, Apter A, Bertolote J, et al: Suicide prevention strategies: a systematic review. JAMA
294(16):2064–2074, 2005 16249421
Miller M, Azrael D, Barber C: Suicide mortality in the United States: the importance of attend
ing to method in understanding population-level disparities in the burden of suicide.
Annu Rev Public Health 33:393–408, 2012 22224886
Nock MK, Borges G, Bromet EJ, et al: Cross-national prevalence and risk factors for suicidal ide
ation, plans and attempts. Br J Psychiatry 192(2):98–105, 2008 18245022
Owens C, Booth N, Briscoe M, et al: Suicide outside the care of mental health services: a case
controlled psychological autopsy study. Crisis 24(3):113–121, 2003 14518644
Parra-Uribe I, Blasco-Fontecilla H, Garcia-Parés G, et al: Risk of re-attempts and suicide death
after a suicide attempt: a survival analysis. BMC Psychiatry 17(1):163, 2017 28472923
Pompili M, Innamorati M, Szanto K, et al: Life events as precipitants of suicide attempts among
first-time suicide attempters, repeaters, and non-attempters. Psychiatry Res 186(2-3):300–
305, 2011 20889216
Poorolajal J, Haghtalab T, Farhadi M, et al: Substance use disorder and risk of suicidal ideation,
suicide attempt and suicide death: a meta-analysis. J Public Health (Oxf) 38(3):e282–e291,
2016 26503486
Powell KE, Kresnow MJ, Mercy JA, et al: Alcohol consumption and nearly lethal suicide at
tempts. Suicide Life Threat Behav 32(1 suppl):30–41, 2001 11924693
Richards JE, Whiteside U, Ludman EJ, et al: Understanding why patients may not report sui
cidal ideation at a health care visit prior to a suicide attempt: a qualitative study. Psychiatr
Serv 70(1):40–45, 2019 30453860
Rimkeviciene J, O’Gorman J, De Leo D: Impulsive suicide attempts: a systematic literature re
view of definitions, characteristics and risk factors. J Affect Disord 171:93–104, 2015
25299440
Rudd MD: Core competencies, warning signs, and a framework for suicide risk assessment in
clinical practice, in The Oxford Handbook of Suicide and Self-Injury. Edited by Nock MK.
New York, Oxford University Press, 2014, pp 323–336
Schmitz WM Jr, Allen MH, Feldman BN, et al: Preventing suicide through improved training
in suicide risk assessment and care: an American Association of Suicidology Task Force re
port addressing serious gaps in U.S. mental health training. Suicide Life Threat Behav
42(3):292–304, 2012 22494118
Silverman MM, Berman AL: Suicide risk assessment and risk formulation. Part I: a focus on sui
cide ideation in assessing suicide risk. Suicide Life Threat Behav 44(4):420–431, 2014
25250407
Simon RI: Patient safety and freedom of movement: coping with uncertainty, in American Psy
chiatric Publishing Textbook of Suicide Assessment and Management, 2nd Edition. Ed
ited by Simon RI, Hales RE. Washington, DC, American Psychiatric Publishing, 2012a, pp
331–346
Simon RI: Suicide risk assessment: gateway to treatment and management, in American Psy
chiatric Publishing Textbook of Suicide Assessment and Management, 2nd Edition. Edited
by Simon RI, Hales RE. Washington, DC, American Psychiatric Publishing, 2012b, pp 3–28
Swanson JW: Explaining rare acts of violence: the limits of evidence from population research.
Psychiatr Serv 62(11):1369–1371, 2011 22211218
Yip PS, Caine E, Yousuf S, et al: Means restriction for suicide prevention. Lancet 379(9834):2393–
2399, 2012 22726520
Youngstrom EA, Hameed A, Mitchell MA, et al: Direct comparison of the psychometric prop
erties of multiple interview and patient-rated assessments of suicidal ideation and behav
ior in an adult psychiatric inpatient sample. J Clin Psychiatry 76(12):1676–1682, 2015
26613136
Yuodelis-Flores C, Ries RK: Addiction and suicide: a review. Am J Addict 24(2):98–104, 2015
25644860
CHAPTER 2
Psychopharmacology and
Neuromodulation
Robert L. Trestman, Ph.D., M.D.
As described in detail throughout this textbook, the characteristics of suicidal

thoughts and behaviors and suicide are complex. Similarly, interventions that directly
impact the functioning of the brain have complex effects. At times, distinguishing
whether suicidal thoughts and behaviors are a manifestation of the underlying illness
or of the treatment can be challenging. The interventions may also be misused: sui
cide by overdose with a therapeutic medication is an intrinsic risk that clinicians must
weigh in treatment planning. In this chapter, we review the data regarding the effec
tiveness and risks of the different classes of psychopharmacological agents and
address the risks and benefits of the rapidly evolving field of neuromodulation.
Psychopharmacology
Virtually any psychopharmacological agent, when taken in combination or at high
enough dosage, can lead to death. This challenge is at the core of managing psychiat
ric illnesses, most of which increase the risk of death from suicide. Many mediators
and moderators of risk exist, including underlying diagnosis, age and sex, cultural
and social supports, past personal and family history, hopelessness, and psychosis. It
is important to provide context as well to the relative lethality of prescription medi
cations themselves commonly used in psychiatry (Giurca 2018).
The authors wish to acknowledge Brian Saway, B.A., currently a third-year medical student at
Virginia Tech/Carilion School of Medicine, for his enthusiastic input, extensive neuromodula
tion literature search, and ideas concerning its use in suicidal thoughts and behaviors.
17
As may be seen in Table 2–1, when we provide a prescription to a patient for a

month’s supply of medication (maximum approved dosages are used in these exam
ples), the potential for lethal overdose varies across two orders of magnitude by the
medication chosen. These estimates do not take into consideration the person’s bio
logical state (e.g., whether someone is already malnourished or dehydrated) or
whether multiple medications may be ingested.
Polypharmacy is a significant suicide risk factor: one recent study found use of anti
psychotic drugs or polypharmacy with four or more medications were predictors of
suicide death (Takeuchi et al. 2017). The type of medication used in an overdose at
tempt is also subject to what is available to the patient. Over the latter half of the twen
tieth century, use of tricyclic antidepressants (TCAs) in overdose was not an uncommon
method of suicide; use of selective serotonin reuptake inhibitor (SSRI) antidepressants
in overdose attempts is increasing, consistent with the transition in use from TCAs to
SSRIs in the treatment of depression (Löfman et al. 2017).
Suicide risk is increased in individuals with mental illness, particularly depression.
Treatment of depression reduces the risk of suicide, whether through pharmacological
means, psychotherapy, or both (Weitz et al. 2014). The presence of suicidal ideation and
behaviors at baseline may also be a predictor of treatment outcome in some populations
(Bingham et al. 2017). Using the most appropriate rating scale in assessing measures
of suicidal ideation remains an important factor as research in this area continues.
Antidepressants
The potential for increased risk of suicidal ideation linked to antidepressant use led
to a black box warning for antidepressant use in 2004 in children, adolescents, and
young adults. Most pharmacoepidemiological studies show a protective effect of an
tidepressants on suicidal ideation and behavior, though others find inconclusive or
mixed results. A recent analysis of suicide deaths in Sweden of young women (ages
15–24 years between 1999 and 2013) found a trend for increased incidence of suicide
death as antidepressant prescriptions increased in parallel (Larsson 2017). A large
French dataset of outpatients newly prescribed antidepressants found that 9% of pa
tients developed suicidal ideation de novo after drug initiation, with 1.7% attempting
suicide (Courtet et al. 2014).
In addition to initial depressive manifestations and an association with suicidal ide
ation and behavior, lack of mood disorder improvement or worsening of symptoms
also increased new thoughts or behaviors of suicide (Courtet et al. 2014). Analysis of
the Northern Finland Birth Cohort of 1966 found that suicidal ideation was associated
with the use of all antidepressants (without any significant difference between classes
or types of antidepressants), but this association was no longer present when other
symptoms of depression and anxiety were considered. Furthermore, insomnia itself
was a predictor of suicidal ideation occurrence for depressed patients taking antide
pressants (Rissanen et al. 2014). A focused review (Brent 2016) on antidepressants and
suicidal thoughts and behaviors in young people found that 4–11 times more de
pressed young people benefit from antidepressants compared to experiencing a sui
cidal event, reflecting the need to not withhold antidepressants from patients and the
potential benefits of careful treatment.
Treatment-emergent suicidal ideation in older depressed adults participating in a
clinical trial was transient, early on in pharmacological exposure, and more likely due
Psychopharmacology and Neuromodulation 19
TABLE 2–1. Maximum daily dosage, LD50, and relative risk of death from
overdose of selected common psychotropic medications
Maximum daily LD50, Relative

Drug class and name dosage, mg mg/kg lethality
Selective serotonin reuptake inhibitors

Escitalopram 20 980 1.0
Fluoxetine 80 452 8.9
Serotonin-norepinephrine reuptake inhibitors
Desvenlafaxine 50 700 3.6
Duloxetine 120 279 21.5
Tricyclic antidepressants
Protriptyline 60 299 10.0
Desipramine 300 320 46.9
Doxepin 300 147 102.0
Other antidepressants
Mirtazapine 45 490 4.6
Trazodone 600 690 43.5
Mood stabilizers
Topiramate 400 3,745 5.3
Lamotrigine 400 205 97.6
Lithium 1,800 525 171.4
Valproic acid 3,600 670 268.7
Antipsychotics
Aripiprazole 30 953 1.6
Quetiapine 800 2,000 20.0
Clozapine 900 251 179.3
Chlorpromazine 800 145 275.9
Anxiolytics
Alprazolam 4 3,100 0.1
Clonazepam 20 4,000 0.3
Note. LD50 is the lethal dose 50% of the time in animal models. The relative risk is based on a 30-day
prescription at the maximum dosage to a 60-kg adult.
Source. Adapted from Giurca 2018.
to the depressive disorder itself rather than an adverse effect of medication (Cristancho
et al. 2017). A very large Danish cohort study analyzing antidepressant prescriptions
over a 10-year period showed an age-dependent decline in suicide rate in both antide
pressant-treated men and women, with an opposite trend demonstrated in those not
treated (Erlangsen and Conwell 2014). Alternatively, those initiated on antidepressants
after age 75 seem to be more prone to suicidal behaviors, particularly if antidepressants
are concomitantly used with anxiolytics and hypnotics (Hedna et al. 2018).
In sum, evidence reflects that adherence to antidepressant treatment of depression
reduces suicide risk. Some evidence indicates that SSRIs decrease suicidal thoughts
more than norepinephrine-dopamine reuptake inhibitors or serotonin-norepinephrine
reuptake inhibitors during treatment (Henein et al. 2016). Other studies do not find a
difference in the rates of suicidal ideation, behavior, or self-harm among classes of an
tidepressants (Valuck et al. 2016).
Another complicating factor related to experimental design is the general exclusion
of patients at high risk of self-harm from clinical trials investigating potential antide
pressant compounds, which has limited the assessment of suicidal ideation and behav
ior as markers of depression. This paradigm has been challenged with demonstrated
transience of suicidal ideation in contrast to the durability of other depressive symp
toms and can safely be investigated in the context of close monitoring. Additionally, the
risk that suicidal thoughts may recur during a subsequent antidepressant or therapy
trial after initial trial failure warrants continued close assessment (Perlis et al. 2012).
Antipsychotics
Antipsychotic medications are used to treat a wide range of psychiatric disorders and
in the full age range of people with, for example, schizophrenia, bipolar disorder, and
major depression. The efficacy of antipsychotic medications for treating psychosis
and mania is well established, with less data generally available as to antisuicidal
properties. The one major exception is clozapine. Clozapine-treated individuals with
schizophrenia demonstrate reduction in rehospitalizations, better adherence to pre
scription refills, and a significantly lower risk of attempted suicide compared to other
antipsychotic medications (Ringbäck Weitoft et al. 2014).
Clozapine’s mechanism of action in reducing suicide behaviors, and by extension that
of other second-generation antipsychotics, is postulated to be due to serotonergic involve
ment or to improved adherence from fewer side effects as compared to first-generation
antipsychotics. Although akathisia, a recognized side effect of many pharmacotherapies,
has been noted to increase the risk of suicide, in most studies this risk in inconsistent. This
finding is hypothesized to be due to the countervailing benefit of treatment adherence
versus lack of treatment in providing a net therapeutic benefit (Reutfors et al. 2016).
The use of first- and second-generation antipsychotics for treating patients with bi
polar disorder is common. The effects of antipsychotics on suicidal ideation and be
haviors in patients with bipolar disorder have not been clearly determined. Tondo
and Baldessarini (2016) reviewed long-term treatment options for patients with bipo
lar disorder and the prevention of suicidal behavior, finding inconsistent benefit.
Clozapine’s antisuicidal benefits have been studied primarily in those with schizo
phrenia or schizoaffective disorder and not in those with bipolar disorder.
Mood Stabilizers
Mood-stabilizing agents have long been used in the treatment of a range of disorders,
most notably bipolar disorder. Early recognition of illness and active treatment engage
ment are recognized as critical to long-term outcome and reduction of suicide risk in
these patients. Longer duration of untreated bipolar illness and elevated risk of suicide
attempts as well as increased frequency of suicide attempts emphasize the importance
of early recognition and aggressive treatment of bipolar disorder (Tsai et al. 2016).
Lithium
The utility of lithium in reducing suicidal thoughts and behaviors is well estab
lished; along with clozapine, it has earned the U.S. Food and Drug Administration
(FDA)’s indication for reducing these. The specific mechanism of action is unknown.
A recent meta-review concluded that the evidence in support of lithium as effective
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of Orphan Dinah
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
restrictions whatsoever. You may copy it, give it away or re-use it
under the terms of the Project Gutenberg License included with this
ebook or online at www.gutenberg.org. If you are not located in the
United States, you will have to check the laws of the country where
you are located before using this eBook.
Title: Orphan Dinah
Author: Eden Phillpotts
Release date: November 14, 2023 [eBook #72130]

Most recently updated: November 29, 2023
Language: English
Original publication: London: William Heinemann, 1920
Credits: Al Haines
*** START OF THE PROJECT GUTENBERG EBOOK ORPHAN

DINAH ***
Orphan Dinah
By
Eden Phillpotts
Author of "Miser's Money," etc.
1920
London : William Heinemann
LONDON: WILLIAM HEINEMANN. 1920.
CONTENTS
CHAPTER
I. THE HILLTOP
II. FALCON FARM
III. SUPPER
IV. AT BUCKLAND-IN-THE-MOOR
V. THE ACCIDENT
VI. ON HAZEL TOR
VII. AT GREEN HAYES
VIII. THE OLD FOX-HUNTER
IX. A HOLIDAY FOR SUSAN
X. TALKING WITH DINAH
XI. NEW BRIDGE
XII. AFTERWARDS
XIII. JOE ON ECONOMICS
XIV. THE FACE ON THE ROCK
XV. BEN BAMSEY'S DOUBTS
XVI. SUNDAY
XVII. DINAH
XVIII. MAYNARD
XIX. LIGHT OF AUTUMN
XX. THE HUNTER'S MOON
XXI. FUNERAL
XXII. AT WATERSMEET
XXIII. IN A SICK-ROOM
XXIV. "THE REST IS EASY"
XXV. JOHN AND JOE
XXVI. MR. PALK SEEKS ADVICE
XXVII. DISCOVERY
XXVIII. THE LAW
XXIX. JOE TAKES IT ILL
XXX. THE NEST
XXXI. JOE'S SUNDAY
XXXII. JANE AND JERRY
XXXIII. JOE HEARS THE SECRET
XXXIV. AN OFFER
XXXV. FOR RIGHT AND JUSTICE
XXXVI. THE WEDDING DAY
XXXVII. SHEPHERD'S CROSS
XXXVIII. RETURN FROM THE HONEYMOON
CHAPTER I
THE HILLTOP
The spectacle of a free horizon from Buckland Beacon, at the southern

rampart of Dartmoor, challenges the least discerning eye by the accident of
its immensity, and attracts an understanding vision for weightier reasons.
Beheld from this high place, Dart Vale and the land beyond it afford a great
composition of nature, orbicular and complete. Its obvious grandeur none
can question, but there is much more to be said for it, and from beneath the
conspicuous and rhetorical qualities there emerge enduring distinctions. The
scene belongs to an order of beauty that does not grow old. Its sensitiveness
to light and the operations of the sky; its gracious, yet austere, composition
and its far flung arena for the masques and interludes of the dancing hours
render it a centre of sleepless variation. Its native fabrics, now gay, now
solemn, are a fit habit for the lyrical and epic seasons, and its garments are
transformed, not only by the robings and disrobings of Spring and Winter,
but at a point's change in the wind, at a rise or fall of temperature. These
delicacies, with the more patent magic of fore-glow and dawn, sunset and
after-glow, crepuscule and gloaming, are revealed under the most perfect
imaginable conditions; for, by many chances and happy hazards, earth here
responds to air in all its heights and depths so completely that each
phenomenon finds all needful for fullest achievement. One might study the
vision a thousand times, yet find no picture resemble another, even in detail
of large forms; for the actual modelling changes, since light and atmosphere
deal with forest, rock and ridge as though they were plastic—suppressing
here, uplifting there, obliterating great passages at one moment and erecting
into sudden prominence things concealed at another. The hill sinks at the
pressure of a purple shadow; the unseen river suddenly sparkles its presence
at a sunbeam.
In this hour, after noon on a day of mid September, the light was
changing, not gradually at the sun's proper declension, but under the forces
of a south-west wind bringing up vapour at twenty miles an hour from the
distant sea.
From the rounded and weathered masses of the Beacon, the hill sloped
abruptly and a receding foreground of dying fern and grey, granite boulders
broke on a gap of such extent that earth, reappearing far below, was already
washed by the milky azure of the air, through which it glimmered and
receded and presently again rose to lofty lands beyond. The ground plan
was a mighty cup, over which the valley undulated, rising here to knap and
knoll, falling there into coombs and plains, sinking to its lowest depths
immediately beneath the view point, where Dart wound about lesser hills,
not small in themselves, yet dwarfed by the greatness of the expanse and
the loftiness of the horizon's brim. Upon that distant and irregular line, now
melting into the thick air, border heights and saliencies sank and rose,
repeating on a vaster scale the anatomy of the river basin. They lifted
through the hazes until they faded upon the sight into the gathering clouds,
that loomed still full of light, above their grey confines. The sea was long
since hidden.
A chief quality of this spectacle appeared in the three dissimilar and

different coverings that draped it. The body of the earth lay wrapped in a
triple robe, and each garment was slashed and broken, so that its texture
flowed into and revealed the others. Every furlong of these rolling leagues,
save only where the river looped and twined through the middle distance,
was clad with forest, with field, or with wilderness of heath and stone; and
all, preserving their special qualities, added character of contrast to their
neighbours. There was not a monotonous passage from east to west in this
huge spectacle. Tilth and meadow oozed out through coppice and hanger;
the forests ascended the steep places and fledged the hills, only drooping
their dark wings where furze and stone climbed higher still, until they
heaved upon the sky. The immemorial heights changed not, save to the
painting of the seasons; the woods, that seemed as ancient as they, were
largely the work of man, even as the tesselated patterns of the fields that
spread, shorn of their corn, or still green with their roots, among them. The
verdant patchwork of mangel and swede, the grey of arrish, and the gloom
of freshly broken earth bosomed out in gentle arcs among the forests,
breaking their ragged edges with long, smooth billows of colour. They
shone against the summer sobriety of the trees, for the solid masses of the
foliage were as yet scarcely stained with the approaching breath of the fall.
But woodlands welcomed the light also, and the sunshine, though already
softened by a gathering haze that advanced before the actual clouds, still
beat into the copse and spinney, to fringe with a nimbus of pale gold the
boss of each great tree and outline it from the rest. Light rained and ran
through the multitude of the trees, drowning their green and raying all their
faces with a dim and delicate fire.
In a gap southward, shrunk to velvet tapestry among clumps and

sheaves of pine and oak, spread the lawns of Holne Chase—great park
lands, reduced by distance to a garden. There the last sun gleam wakened a
transient emerald; then it was gone, as a jewel revealed for a moment and
hidden in its casket again.
The woods of Buckland bear noble timber and each tree in many a glen
is a giant, thrusting upward from vast bole to mossy branch, until its high
top ascends among its neighbours to sunlight and storm. They are worthy of
the hills that harbour them, and in their combined myriads affect the
operations of the air, draw the rain clouds for their own sustenance and help
to create the humidity that keeps Dart Vale so dewy and so green. Down
and down they roll endlessly, sinking away into the likeness of a clinging
moss; for seen afar, they look no more upon this great pattern of rising and
falling earth, than a close integument. Their size is lost against the greater
size of the undulations they clothe; they shrink to a close pelt for the land—
no heavier than the leagues of the eagle fern, or the autumnal cloth of
purple and gold flung upon the hills above them.
To-day the highest lights were in the depths, where Dart flashed at a
fall, or shone along some placid reach. She was but a streak of polished
silver seen from aloft, and her manifold beauties hidden; while other remote
spots and sparks of light that held the eye conveyed no detail either. They
meant a mansion, or the white or rosy wash on cottage faces. A grey
smudge, sunk in the green to westward, was a village; a white lozenge in
the woods beneath, the roof of a moorland church. Here and there blue
feathers of wood smoke melted upward into the oncoming clouds; and
thinly, through vapours beyond, like a tangle of thread, there twined high
roads, ascending from invisible bridges and hamlets to the hills.
And then, little by little, detail faded and the shadows of the clouds
grew denser, the body of the clouds extended. Still they were edged with
light, but the light died as they thickened and lumbered forward, spreading
their pinions over the Vale. The air gradually grew opaque, and ridge after
ridge, height after height, disappeared in it. They were not blotted out, but
washed away, until the fingers of the rain felt dumbly along the bosom of
Buckland Beacon, dimmed the heath and furze to greyness, curled over the
uplifted boulder, found and slaked the least thirsty wafer of gold or ebony
lichen that clung thereto.
A young man, who had been standing motionless upon the Beacon, felt
the cool brush of the rain upon his face and woke from his reverie. He was
of a recipient, intelligent aspect, and appeared to admire the great spectacle
spread before him; but whether, behind the thing seen, any deeper emotion
existed for him; whether to the outward and visible sign there responded
any inward and spiritual grace, was a question not to be answered
immediately. He prepared to descend, where a building stood upon the hill
below him half a mile distant. There he was expected, but as yet knew it
not.
CHAPTER II
FALCON FARM
Beneath the Beacon, across the great slope that fell from its summit to
the river valley, a road ran into the woods that hid Buckland village, and
upon the right hand of this highway, perched among open fields, that
quilted the southern slope of the heights, there stood a stone house. Here
was Falcon Farm, and over it the hawks that had given it name would often
poise and soar and utter their complaining cries. The cluster of buildings
perched on the hillside consisted of a slate-roofed dwelling house, with
cartsheds, a cowhouse, and stable and a fine barn assembled round the farm
yard. About them stretched square fields, off some of which a harvest of
oats had just been shorn; while others were grass green with the sprawling
foliage of turnip. Beneath, between the farmhouse and the wooded road,
extended meadows into which fern and heath were intruding ominously. A
little wedge of kitchen garden was scooped out of the hill beside the yard
and a dry-built wall fell from the shoulder of the Beacon above, broke at
Falcon Farm, and with diverging arms separated its field and fallow from
the surrounding wild.
The door of the dwelling faced west, and here stood a man talking to a
woman.
He was of sturdy build with a clean shaved, fresh-coloured face and

head growing bald. But he had plenty of grey hair still and his countenance
was plump and little wrinkled. His eyes were grey and, having long learned
the value of direct vision in affairs, he fixed them upon people when he
talked. Mr. Joseph Stockman declared himself to be in sight of seventy; but
he did not appear so much and his neighbours believed this assertion of age
no more than an excuse for his manner of life.
Indeed, at this moment, his companion was uttering a pleasantry at the

farmer's expense. She had come on an errand from Buckland village, a mile
away, and loitered because she esteemed the humorous qualities of Mr.
Stockman and herself found laughter a source to existence. She needed this
addition. Her lot had not been one of great emotions, or pleasures, for
Melinda Honeysett was a widow after three uneven years of marriage. They
passed before she was five and twenty, when a drunken husband, riding a
horse that would not "carry beer," was pitched off in the night on Dunstone
Down and broke his neck. She had no children and now lived with a bed-
ridden father and ministered to him in the village. This had been her life for
nearly twenty years. She was a connection of Joseph Stockman through her
marriage, for the Bamseys and the Stockmans and the Honeysetts were
related, though neither family exactly knew how.
"A day of great events," said the farmer. "My two new hands both
coming and, as my manner is, I hope the best, but fear the worst."
"A horseman and a cowman, so Susan said."
"Yes. But that means more than the words on a little place like this, as I
made clear. In fact, they've got to do pretty much everything—with such
help as I can give and Neddy Tutt."
"Hope they'll be all right. But they mustn't count on a poor, weak, old
man like you, of course."
Mr. Stockman looked into Melinda's face. She was a chubby, red-haired
woman built on massive lines with a bosom that threatened to burst its
lavender print, and a broad, beamy body beneath. She had a pair of pale
blue eyes and a finely modelled mouth, not devoid of character. Her teeth
were neglected. She wore a white sunbonnet, which threw a cool shadow
over her face, and carried a basket, now full of small carrots and large
lettuces.
"You poke your fun at me, forgetting I've done ten men's work in my
time and must slack off," he said. "Because, thanks to plain living and
moderation in all things, and the widowed state with all its restfulness, I
don't look my age, that's not to say I don't feel it, I can assure you. There's
certain rights I owe to myself—the only person as ever I did owe anything
to in my life—and even if I was fool enough to want to make a martyr of
myself, which I'm not—even so Soosie-Toosie would never let me."
"I'm sure she wouldn't."
"My daughter knows where the shoe pinches; and that's in my breathing
parts. Often I'll stand to work like a young man, knowing all the time I shall
have to pay for it with a long rest after."
"Poor chap!"
He shook his head.
"You be among the unbelievers I see—that's your father's bad work. But
since he don't believe in nothing, I can't hope he'll ever believe in me."
"But the new men. Tell me about them. What are they like?"
"Ah, you females! It's always the outside of a man as interests you. For
my part it was what their papers and characters were like that I had to think
about; and even so I've took one largely on trust."
"You're such a trustful creature, Joe."
"I like to trust. I like to do unto others as they should do unto me. But
it's a disappointing rule of life. To be above the staple of your fellow
creatures is to get a lot of shocks, Melinda; but you can only set a good
example; you can't make people follow it. One man I have seen, t'other I
have not. Thomas Palk, the horseman—so to call him—is in sight of
middle-age and a towser for work. He's leaving Haccombe, down Newton
Abbot way, because his master's son is taking up his job. A very good man
by all accounts, and he understands the position and knows what lies before
him. A faithful-looking man and I hope he'll prove so. Plain as a bit of
moor-stone—in fact a mighty ugly man; but an honest face if I know
anything."
"Sounds all right."
"T'other I haven't seen. He comes from up country and answered my

advertisement. Can't give no character direct, because his master's died
sudden. But he's been along with him for nearly five years, and it was a
bigger place than this, and he writes a very good letter. In fact an educated
man seemingly, and nobody's the worse for that if it don't come between
them and work. Though I grant it be doing so."
"So father says."

"Lawrence Maynard he's called. I've engaged him and hope for the best.
Both free men—no encumbrances. I hope, with my gift of making the
darkness light where farming is concerned, they'll soon be pulling their
weight and getting things all ship-shape."
"Father says nobody knows better than you what work means; but
somebody else has always got to do it."
"A wonderful man your father; yet I'm very much afraid he'll go to hell
when the end comes, Melinda."
"He's not."
A ginger-coloured lurcher appeared. It was a gaunt and hideous dog

with a white muzzle. Behind it came a black spaniel and a white, wire-
haired fox-terrier.
"Us must get to work," said Mr. Stockman. "Soosie-Toosie wants a

brace of rabbits for supper to-night and I'd best to fight for 'em afore the
rain comes. It have been offering since morning and will be on us afore
nightfall."
The dogs, apparently understanding, sat round with their eye on Joseph.
"If your godless parent was to see these poor creatures to work, I can
tell you what he'd say, Melinda. He'd say thicky spaniel was like me—
knows her job very well indeed and prefers to see the younger dogs doing
it. And why not?"
"No use growing old if you don't grow artful," admitted Melinda.
"Of course it ban't—here's the girl. What's the matter now, Soosie? The
rabbits? I be just going after 'em."
But Miss Stockman, Joseph's only child, had not come about the rabbits.
She was a woman resembling her father in no respect. Her hair was black,
lustreless and rough, her brown face disfigured by a "port wine" stain that
descended from her forehead to her cheek. Her expression was anxious and
careworn, and though large-boned and powerfully made, she was thin. She
had brown, dog-like eyes, a mouth with sad lips and a pleading voice,
which seemed to have the same querulous note as the hawks that so often
hung in air above her home.
"Mr. Maynard's box have come, father," she said. "Be he to live in the
house, or to go in the tallet over the stables? Both rooms are sweet and
ready for 'em."
"Trust you for that, Soosie," declared Melinda.
"The horseman goes over the stables, as being the right and proper place
for him," said Mr. Stockman. "And if there was a dwelling room over the
cows, the cowman would go there. But there is not, so he'll come in the
house."
"Right then," answered his daughter. "Mr. Maynard comes in the house;
Mr. Palk goes over the hosses."
Susan disappeared and Mrs. Honeysett prepared to depart.
"And you tell your father that so soon as the woodcock be back—not
long now—he'll have the first. I don't bear no malice."
"We all know that. And when you shoot it, you come in and have a tell
with father. You do him good."
"And you too I hope?"
"Of course you do—such a long-sighted man as you."
She descended down the farm road to the highway beneath, and Joseph,
getting his gun, went upwards with his rejoicing dogs into the fern brakes
on the side of the Beacon.
Here, in the pursuit of the only exercise he really loved, Joe Stockman
forgot his alleged years. He was a wonderfully steady shot, though it suited
him to pretend that failing sight interfered very seriously with his sport; but
he excelled still in the difficult business of snapping rabbits in fern. Thus
engaged, with his dogs to help him, he became oblivious of weather and it
was not until the sight of an approaching stranger arrested him that he grew
conscious of the rain. Then he turned up his collar over his blue woollen
shirt and swore.
The man who had recently surveyed Dart Vale from the summit of the
rocks above, was now descending, and seeing the farmer, turned his steps
towards him. He was a slight-built but well-knit youth of seven or eight and
twenty. He stood an inch under six feet and was somewhat refined in
appearance. His face was resolute and cleanly turned, his skin clear and of a
natural olive, that his open-air life had tanned. He wore a small, black
moustache over a stern mouth, and his eyes were very dark brown and of a
restless and inquiring expression. He wore rough, old tweeds, a little darned
at the seat, and on his left arm over the elbow was a mourning band. His
legs were cased in tawny gaiters; he had a grey cap on his black hair and in
his hands he carried an ash sapling with which, unconsciously from habit,
he smote his leg as he walked.
"Sorry to spoil sport," he said, in a quick, clear voice somewhat low

pitched, "but I'm a stranger in these parts and want Falcon Farm. Be I right
for it?"
"Very right indeed," answered Mr. Stockman. "In fact, so right that it's
under your nose. There's Falcon Farm, and I'm the farmer, and I guess
you're Lawrence Maynard, due to-day."
The other smiled and his habitual solemnity lifted off his face.
"That's right. I walked from Bovey, because I wanted to have a look at

the country."
"And what d'you think of it?"
"Fine. After flat Somerset it makes your legs wake up."
"I dare say it would. There's nothing like a hilly country for tightening
the muscles. The Shire hosses find that out when they come here. Yes, that's
Falcon Farm. And there's the cows—all red Devons."
The newcomer looked down upon a little cluster of kine grazing in a
meadow.
"A beautiful spot sure enough. And snug by the look of it."
"Nothing to grumble at for high land. But it calls for work. I've been
here five and twenty year and made it what it is; but I'm old for my age,
along of hard labour in all weathers, and can't do all I would no more.
However, we'll tell about it later when my other new man, Thomas Palk,
arrives. Horseman, he is; but, as I explained, you and him are going to be
my right and left hand now, and I can see you're the quick sort that will
justify yourself from the first."
"I hope so."
"Heave up them rabbits then, and we'll go down along. I can stop a bird
or beast still, though getting cruel dim in the eye."
Maynard picked up three heavy rabbits and they went down the hill
together.
"We're a small party," explained Joe, "but very friendly, easy people—
too busy to waste time on differences. And you and Palk will find
yourselves very comfortable I hope. There's only me and my daughter, Miss
Stockman, who rules us men, and a young boy, Neddy Tutt, whose making
up into a useful hand. At hay harvest and corn harvest I hire. We've just got
home our oats. For the roots, we can pull them ourselves. Of the men who
have left me, one went for faults, and we can let the past bury the past;
t'other found the winter a thought too hard up here and have gone down to
the in-country. He's wrong, but that's his business."
The newcomer felt favourably impressed, for Mr. Stockman had great
art to win strangers. He promised to be a kindly and easy man, as he
declared himself to be.
Lawrence patted the dogs, who sniffed round him with offers of
friendship, and presently all returned together.
CHAPTER III
SUPPER
"I must go and change my coat," said the farmer as they entered the
house place. "There was a time when I laughed at a wet jacket, same, no
doubt, as you do; but that time's past. Here's my daughter. She'll show you
your room."
Susan shook hands and her hurried, fitful smile hovered upon the new
arrival.
"Your box be come and I'll give you a hand up," she said. "Your room's
in the house at the end of the passage-way facing east. A very comfortable
room I hope you'll find."
"Thank you, miss. But I'll fetch up the box if you'll show the way."
He shouldered it and followed her.
"Us'll be having dinner in a minute," she said. "Faither likes it at half

after one. Mr. Palk ban't arriving till the afternoon."
During the afternoon Mr. Palk did arrive. He drove up from Ashburton
in a trap hired at an inn and brought his luggage with him. He proved a
broad and powerful man of fifty, iron grey, close bearded and close
cropped. His head was set on a massive neck that lifted above heavy
shoulders. His features were huddled together. His nose turned up and
revealed deep nostrils; his mouth was large and shapeless; his eyes were
steadfast. He proved a man with great powers of concentration. Thus his
modest intelligence took him farther than many quicker wits lacking that
gift. He did not see much beyond his immediate vision, but could be clear-
sighted enough at close range. He had no humour and received impressions
slowly, as a child; but grasped them as a child. A light touch was thrown
away on Mr. Palk, as his new master soon found. Nod or wink were alike
futile as means of suggestion: it was necessary to speak plainly that he
might grasp a point. But, once grasped, the matter might safely be left. He
never forgot.
At tea that night Joe Stockman expatiated on the situation and his new
men listened, while the lad, Neddy Tutt, a big, fair youth, intently regarded
them and endeavoured to judge their probable attitude to himself. He was
inclined to like both, but doubted not they were on their best behaviour at
present and might develop character averse from his interests.
"There's no manner of doubt that we're a little behind," confessed the

master. "There are things you'll be itching to put right this autumn, I expect;
and I doubt if men like you will rest till we're up to the mark again. When I
was young, I had a hawk's eye for danger, and if I saw the thistles gaining
on the meadow-land, or the fern and heath getting in while our backs was
turned, I'd fight 'em tooth and nail and scarcely rest in my bed till they was
down and out. On Dartmoor the battle's to the strong, for we're up against
unsleeping forces of Nature as would rather hinder than help. In a word the
work's hard, but I lead the way, so far as my weight of years allow it; and,
what's more to the point, as you'll find, is my ideas on the subject of food
and money. The money you know about; the food you don't. I attach a very
great deal of importance to food, Mr. Palk."
Thomas Palk nodded.
"Them as work did ought to eat," he said.
"They did; and I'm often shocked in my observing way to see farmers
that don't appear to think so. We keep a generous table here and a good
cook likewise, for what my daughter don't know about a man's likes and
dislikes in the matter of food ain't worth knowing. As to hours, what I say is
that in private service, for that is how you must look at yourselves with me,
hours are beside the question. Here's the work and the work must be done;
and some days it's done inside seven hours I shouldn't wonder, and some
days it's not done inside eight. But only the small mind snaps and snarls for
a regulation hour, and it is one of the most mean things to a man like me,
who never thought of hours but only the work, that poor spirits here and
there be jealous of the clock and down tools just because of the time of day.
For look at it. We ain't all built on the same pattern, and one man can do his
sort of work an hour a day quicker than another, whether it is ploughing, or
harvesting or what not; and the other man can do something else an hour a
day quicker than he can. So I'm for no silly rules, but just give and take to
get the work done."
"A very self-respecting sort of way, and much what I'm used to," said
Maynard.
"Same with liquor," continued Joe. "On the subject of liquor, I take a
man as I find him. I drink my beer and take my nightcap also, and there's
beer and cider going; and if in drouthy weather a man says, 'I want another
half pint,' the barrel's there. I'm like that. I like to feel the respect for my
people that they always get to feel for me. But spirits, no. I might, or I
might not of an evening say to you, 'Have a spot from my bottle, Palk'; but
there wouldn't be no rule."
"I'm teetotal myself," said Maynard, "but very fond of cold tea in
working hours."
"Good. You'll never have less cold tea than you want, be sure."
"I be a thirsty man," confessed the elder. "Beer's my standby and I'm
glad you grant it; but I only drink when I'm thirsty, though that's often,
owing to a great freedom of perspiration. But no man ever saw me bosky-
eyed, and none ever will."
"All to the good, Palk. So there it stands. And one more thing: till you
know the ropes and my manners and customs, always come to me when in
doubt. Your way may be a good way, but where there's two ways, I like
mine, unless you can prove yours better. That's reasonable—eh?"
"Very reasonable," admitted Maynard.
"The horses are a middling lot and can be trusted to do their work. I'm
buying another at the Ashburton Fair presently. My sheep—Devon long

Full Ebook of Textbook of Suicide Risk Assessment and Management 3Rd Ed Liza H Gold Online PDF All Chapter

Uploaded by

Copyright:

Available Formats

Full Ebook of Textbook of Suicide Risk Assessment and Management 3Rd Ed Liza H Gold Online PDF All Chapter

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Full Ebook of Textbook of Suicide Risk Assessment and Management 3Rd Ed Liza H Gold Online PDF All Chapter

Uploaded by

Copyright:

Available Formats

Textbook of Suicide Risk Assessment

and Management 3rd ed Liza H. Gold

The Global Human Resource Management Casebook 3rd

Project Management for IT Related Projects 3rd ed Bob

Assessment and Management of Pressure Injuries for the

Oxford Textbook of Suicidology and Suicide Prevention

Textbook Of Polytrauma Management: A Multidisciplinary

Suicide Assessment and Treatment Planning A Strengths

Assessment and Communication of Risk 1st Edition Eric

Fundamentals of Risk Management: Understanding,

Liza H. Gold, M.D.

1 Suicide Risk Assessment. . . . . . . . . . . . . . . . . . . . . . 3

2 Psychopharmacology and Neuromodulation . . . . . . 17

3 Cognitive and Behavioral Therapy . . . . . . . . . . . . . . 29

5 Split Treatment: The Psychiatrist’s Role . . . . . . . . . 51

8 Anxiety Disorders, Obsessive-Compulsive

9 Substance-Related Disorders . . . . . . . . . . . . . . . . 109

10 Bipolar Spectrum Disorders . . . . . . . . . . . . . . . . . . 123

12 Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . 147

13 Sleep and Suicide . . . . . . . . . . . . . . . . . . . . . . . . . 159

14 Emergency Services . . . . . . . . . . . . . . . . . . . . . . . 175

15 Outpatient Treatment of the Suicidal Patient . . . . . 189

16 Inpatient Treatment . . . . . . . . . . . . . . . . . . . . . . . . 201

18 Children and Adolescents . . . . . . . . . . . . . . . . . . . 227

19 College and University Students . . . . . . . . . . . . . . 239

20 Suicide in the Elderly Population . . . . . . . . . . . . . . 251

21 Jails and Prisons . . . . . . . . . . . . . . . . . . . . . . . . . . 265

22 Military Personnel and Veterans . . . . . . . . . . . . . . 279

23 Suicide and Gender . . . . . . . . . . . . . . . . . . . . . . . . 293

24 Self-Injurious Behavior . . . . . . . . . . . . . . . . . . . . . . 305

25 Social Media and the Internet . . . . . . . . . . . . . . . . 321

26 Physician-Assisted Dying. . . . . . . . . . . . . . . . . . . . 335

27 Suicide Risk Management:

28 The Psychological Autopsy and

29 Suicide and Firearms . . . . . . . . . . . . . . . . . . . . . . . 379

30 Suicide Prevention Programs. . . . . . . . . . . . . . . . . 391

31 Teaching Suicide Risk Assessment in

Peter Ash, M.D.

Claudia Avina, Ph.D.

Alaina Baker, B.S.

Richard Balon, M.D.

Michele Berk, Ph.D.

Kimberly Brandt, D.O.

Beth S. Brodsky, Ph.D.

Juan José Carballo, M.D.

Stephanie Clarke, Ph.D.

Victoria Cosgrove, Ph.D.

Katrina DeBonis, M.D.

Nathan Fairman, M.D., M.P.H.

Antonio Fernando, M.D., ABPN

Susan Hatters Friedman, M.D.

Richard L. Frierson, M.D.

Rachel Funk-Lawler, Ph.D.

Glen O. Gabbard, M.D.

Michael Gitlin, M.D.

Liza H. Gold, M.D.

Derrick A. Hamaoka, M.D.

Annette Hanson, M.D.

Lindsay M. Hayes, M.S.

Decisions regarding specific treatment interventions rely on recognition of dy