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PPD: 3 keys to assessing suicide risk

Patients who engage in ‘escalating attempts’ are at a higher risk of harming themselves

Vol. 9, No. 6 / June 2010

In the United States >33,000 people take their lives each year.1 Depression is involved in 65% to 90% of all suicides;2 however, some patients may not appear acutely depressed or might minimize suicidal thoughts to avoid treatment or hospitalization.

Having direct patient contact, information from collateral sources, and available medical records will guide you in developing a treatment plan, but also consider these 3 areas using the mnemonic PPD:

Past suicide attempts. One of the best predictors of future suicidal behavior is past attempts.3 Ask your patient if he or she has engaged in suicidal behaviors of increasing lethality, such as overdosing, cutting, or unintentional firearm injury. Patients who engage in “escalating attempts” are at a higher risk of harming themselves.4

Psychosis. Actively psychotic patients have difficulty contracting for safety. They may report hearing voices telling them to harm themselves or others. Ask patients about hallucinations and how they respond to these experiences even if the hallucinations do not involve suicidal content. For example, a patient with a delusion of having a deadly infectious disease may ingest an entire bottle of medication to eradicate the infection. This might seem like a suicide attempt, but the patient’s intent was not to die, but to “treat” himself or herself.

Drugs and alcohol. One-third of those who commit suicide test positive for alcohol and nearly 1 in 5 have evidence of opiates.5 Patients may abuse substances to regulate their moods; however, they are prone to suicidal behavior under the influence of drugs or alcohol. Ask your patient about substances he or she uses and how they impact suicidal thoughts.

Positive findings for ≥1 of the above criteria place a patient at higher risk for suicidal behavior.6 By incorporating these 3 factors into your suicide assessment, you will be better equipped to justify the level of care and treatment you recommend.


1. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at: Accessed April 22, 2010.

2. Blumenthal SJ. Suicide: a guide to risk factors, assessment, and treatment of suicidal patients. Med Clin North Am. 1988;72:937-971.

3. Moscicki EK. Epidemiology of suicidal behavior. In: Silverman MM, Maris RW, eds. Suicide prevention: toward the year 2000. New York, NY: Guilford; 1985:22–35.

4. American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders Compendium. Arlington, VA: American Psychiatric Association; 2004: 835–1027.

5. Karch DL, Dahlberg LL, Patel N, et al. Surveillance for violent deaths–national violent death reporting system, 16 states, 2006. MMWR Surveill Summ. 2009;58:1-44.

6. Oquendo MA, Malone KM, Ellis SP, et al. Inadequacy of antidepressant treatment for patients with major depression who are at risk for suicidal behavior. Am J Psychiatry. 1999;156:190-194.

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