The risk of suicide is a concern in all depressed patients. Between 11% and 17% of people who have suffered a severe depressive disorder at any time will eventually commit suicide. 10 Referral for hospital admission should be arranged for patients who are at great risk for suicide. There is a distinction between patients who are determined to suicide and those who attempt suicide (parasuicide).

Risk factors for suicide include:

• adolescents

• young adults 15-25 years

• immigrant status

• isolation/living alone

• recent divorce, separation or bereavement

• recent loss of employment or retirement

• family history of psychiatric illness (including suicide)

• impulsive, hostile personality

• previous suicide attempt

• severe depression

• financial difficulties

• alcohol or other substance abuse

• early dementia

• physical illness, especially if chronic pain

A useful suicide risk assessment is the SAD PERSONS (mnemonic) index ( Table 16.2 ). A score greater than 7 represents a very high risk that demands careful attention including referral to an acute psychiatric service.

Table 16.2 SAD PERSONS Index: Suicide risk assessment

Risk factor Criteria Score




< 20 years; > 45 years


Major, e.g. depressed mood

Psychiatric history

Previous attempts

Excessive drug use

Ethanol or other drug abuse

Rationality loss

Psychosis, severe depression


Loss of spouse or other single

Organised plan

Determined suicide plan

No supports

No community back-up; generally isolated


Chronic illness

Score > 7 = high suicide risk

If there is concern about suicide risk and treatment is supervised outside hospital, provide closer supervision and considerable support, and prescribe drugs that are less toxic in overdosage, e.g. mianserin or fluoxetine. If tricyclics are prescribed, useful guidelines are that dangerous medical complications occur with an equivalent dosage of 1000 mg (40 tablets) of imipramine and a high risk of death with 2000 mg (80 tablets). 6

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