Suicide stands as a profoundly tragic outcome within clinical practice, unpredictable in individuals and stemming from a complex interplay of factors varying across people. Notably, a significant 30%–70% of suicides occur among patients already receiving some form of treatment [1–3]. A deeper understanding of the biological, clinical, and situational factors involved in suicide is crucial for clinicians to effectively recognize risk factors and implement timely interventions to mitigate suicide risk.
1.1. DIAGNOSIS
Suicide is not confined to any single psychiatric diagnosis; however, research consistently highlights its higher prevalence in mood disorders, particularly major depressive disorder and bipolar disorder [4]. Elevated suicide rates are also observed in a spectrum of other conditions, including mixed drug abuse, alcohol and opioid abuse, eating disorders, schizophrenia, personality disorders, and even acute stress disorders [4,5]. It’s suggested that the common thread linking these conditions to suicide may be the presence of mood depression, severe anxiety, and heightened trait impulsivity, which can manifest across various psychiatric disorders [6]. The heightened risk of suicide is particularly emphasized in bipolar disorder [7]. Furthermore, the impact of early child abuse is increasingly recognized as a significant factor contributing to elevated suicide risk [8]. Child abuse is considered to be linked to both early-onset mood disorders and the trait of impulsivity [8].
1.2. TRAITS
Recent studies on suicidal behavior have increasingly focused on behavioral traits that mediate suicide risk. Strong evidence supports the familial-genetic transmission of suicidal behavior, with growing evidence pointing to specific behavioral traits as mediators of this risk [8–12].
Angry impulsivity is a trait consistently identified as a significant risk factor for suicidal behavior [6,8–12]. While impulsivity is observed across various diagnoses, it is particularly associated with bipolar disorder, substance abuse, cluster B personality disorders, and a history of early child abuse [6,9]. A study involving prisoners with a family history of suicide revealed elevated scores for neuroticism and hostility, in addition to impulsivity [13].
Suicide risk factors are broadly categorized into chronic high-risk factors and immediate or acute high-risk factors. A prior suicide attempt is widely recognized as the most significant risk factor in numerous studies [4,14], although the actual suicide rate in individuals with prior attempts is around 5%–10%. A previous suicide attempt can indicate the presence of impulsivity. However, relying solely on past suicidal behavior for risk assessment can be misleading. Isometsa and Lonnqvist [15] reported that approximately 62% of male suicides and 38% of female suicides were first-time attempts.
Suicidal ideation, especially when accompanied by a suicide plan, is considered a strong predictor of risk. However, the absence of reported suicidal ideation or plans does not reliably indicate low risk. This is illustrated by Isometsa et al.’s [16] study of 100 suicides, where only 22% of patients expressed suicidal thoughts during their last psychiatric visit. Similarly, Busch et al. [17] found that 76% of inpatient suicides involved nursing notes documenting the patient’s denial of suicidal ideation just before the act. Therefore, denying suicidal intent should not be taken as a definitive sign of low risk but should be considered alongside the patient’s history, life circumstances, and current clinical state.
Angry impulsivity remains a chronic high suicide risk factor, which, when combined with specific situations [6,8,18–20], mood states, or anxiety, can precipitate suicidal behavior. Other chronic risk factors include male gender, living alone, handgun ownership, and a history of chronic pain [21–24].
In suicide risk assessment, a patient may present as chronically high-risk but not acutely so at the time of evaluation. Chronic risk factors can influence a clinician’s perception of a patient’s current risk level. The term “high-risk group” acknowledges that while individual suicide prediction is challenging, certain risk factors can categorize a patient as higher risk, warranting appropriate management. While chronic risk factors aid in actuarial predictions for groups, the patient’s clinical state, current life situation, and chronic risk factors are crucial for clinicians in determining acute risk and guiding management strategies.
The patient’s current clinical state, recent clinical history, and recent life stresses are vital in assigning risk status and planning effective treatment.
1.3. CLINICAL STATE
A thorough assessment of a patient’s current clinical state and life situation is paramount in determining acute suicide risk. Recent worsening of depressive or anxiety symptoms is a critical indicator requiring comprehensive suicide assessment. The presence of a mixed state, characterized by depressive symptoms alongside manic or hypomanic features, is often linked to increased activity, impulsiveness, severe anxiety/agitation, and consequently, a higher risk of suicidal behavior.
Key high-risk periods include recent admission to or discharge from a psychiatric inpatient facility, with the risk remaining elevated for up to a year post-discharge [15,25–27]. Recent significant losses such as the death of a loved one, divorce, major financial setbacks, job loss, severe medical diagnoses (e.g., cancer), or legal issues can trigger suicidal states, particularly in individuals with depression or high impulsivity [5,28–30]. Assessing a patient’s coping mechanisms in response to such life events is essential.
A clinical state assessment should evaluate coping with life stress and recent increases in negative traits like negative affect. Increased alcohol use, which can exacerbate angry impulsivity [25,31], and the emergence of comorbid anxiety, agitation, or substance abuse [25,31] are also critical factors to consider.
1.4. COMORBID ANXIETY: DYSPHORIC AROUSAL
The nature of “comorbid” anxiety in mood disorders is still under investigation – whether it’s a distinct comorbid anxiety disorder or an inherent aspect of mood disorder symptomatology. Current diagnostic systems differentiate between mood disorders like major depression and bipolar depression, and anxiety disorders. However, a study using the Schedule for Affective Disorders and Schizophrenia, Current (SADS-C), revealed moderate anxiety in 62% and panic attacks in 29% of major depression patients [32]. Clayton et al. [33] also reported high frequencies and severity levels of anxiety symptoms in over 300 patients with primary depression. The frequent co-occurrence of anxiety and depression raises questions about whether anxiety should be considered a core symptom of major depression and bipolar depression, with or without mixed states.
In a 1990 prospective study, Fawcett et al. [25] tracked 954 patients with major affective disorders over 10 years, noting 13 suicides in the first year and 34 over the decade. While prior suicide attempts, suicidal ideation severity, and hopelessness were not significantly higher in the first-year suicides compared to non-suicides, psychic anxiety and panic attack levels were significantly more severe at baseline in the suicide group. A subsequent study by Hall et al. [34] found elevated psychic anxiety in 90% of 100 patients hospitalized for suicide attempts in the month preceding their attempt.
Busch et al.’s [17] 2003 review of 76 inpatient suicides revealed severe anxiety and/or agitation in 79% of cases for 3–7 days prior to suicide, even though 76% had denied suicidal ideation in their last documented communication. Simon et al.’s [35] 2007 review of 32,000 bipolar disorder cases showed that comorbid GAD was associated with elevated suicide risk (OR = 1.8) and attempts (OR = 1.4). While comorbid substance abuse increased attempt rates, it did not elevate suicide risk in this sample [35].
A 2008 Norwegian study by Stordal et al. [36] of over 60,000 subjects showed a simultaneous peak in depression and anxiety severity during the month of suicide (r = 0.72, p = .01), peaking in spring and early fall (p = .01). Pfeiffer et al.’s [37] study of over 887,000 veterans with depression found suicide significantly linked to comorbid GAD, anxiety disorder NOS, and panic disorder, but not PTSD or other anxiety disorders (OR = 1.8). Increased suicide risk was also associated with antianxiety medication use (OR = 1.8), further elevated with high doses (OR = 2.2), suggesting anxiety severity, rather than just disorder presence, is linked to suicide, as supported by Fawcett et al. [32].
While studies on bipolar patients haven’t found comorbid GAD linked to prior suicide attempts, it’s argued that attempts and completed suicides aren’t equivalent, and these studies didn’t measure anxiety severity at the time of attempts [37].
Nock et al.’s [6] cross-national study of over 100,000 subjects found suicide associated with co-occurring anxiety. Nock proposed that while depression correlates with suicidal thoughts, anxiety and poor impulse control drive suicidal behavior [6], a finding supported by Brown et al. [38] in personality and mood disorders, linked to low CSF 5-HIAA levels, indicating reduced brain serotonin turnover associated with impulsivity. Swann et al. [20] connected increased impulsivity to more frequent suicide attempts, and Taylor et al. [39] found anxiety increases impulsivity in bipolar patients.
Bunney and Fawcett [40] in 1965 reported elevated 17-hydroxycorticosteroids (cortisol metabolite) in the days before suicide in three cases. Subsequent studies found HPA axis overactivity in suicide victims via the dexamethasone suppression test [42–46]. Except for one schizophrenic patient with anxiety reported by Sachar et al. [47], these cases didn’t overtly manifest anxiety or dysphoric hyperarousal. Sachar’s patient exhibited “ego disintegration” without depression. This raises the question of whether state anxiety or dysphoric hyperarousal, correlating with HPA axis overactivity, is a clinical symptom in individuals on the verge of suicide.
It’s possible that increased anxiety symptoms in major depression or bipolar disorder are not secondary to comorbid anxiety but are features of the primary mood disorder itself. Incorporating an anxiety severity dimension into DSM-V mood disorder diagnoses could highlight anxiety’s role in mood disorder outcomes and promote better treatment for severe anxiety symptoms in these patients.
The STAR*D study showed that severe anxiety predicted poor antidepressant treatment response [48,49]. Coryell et al. [50,51] demonstrated that higher baseline anxiety severity predicts longer depressive episodes in major mood disorder patients over 16–20 years.
Severe anxiety or dysphoric hyperarousal is a critical clinical state variable for suicide risk management. Increased impulsivity related to anxiety/arousal in response to negative events also warrants consideration. While not universal, inpatient suicide studies have found this in 76% of cases [17], and outpatient suicide reviews suggest it in over half. Severe anxiety/dysphoric hyperarousal may be a key clinical indicator of imminent suicide risk. However, some patients plan suicide meticulously, showing no anxiety/hyperarousal, appearing calm, and concealing their intent, making intervention nearly impossible.
1.5. COMORBID SUBSTANCE ABUSE
Increased substance abuse is another crucial comorbid factor to assess. Alcohol and other substance abuse are well-known risk factors for suicidal behavior [31]. Studies have shown recent moderate alcohol abuse onset in the weeks/days before suicide, possibly as self-treatment for severe anxiety and insomnia. The disinhibiting effects of substances increase impulsivity and impair judgment, elevating suicide risk.
Harris and Baraclough’s [4] review highlighted elevated suicide rates in mixed drug abuse, opioid abuse, and alcohol abuse. Worsening substance abuse severity may indicate heightened suicide risk.
1.6. SHOULD THERE BE A DIAGNOSIS OF SUICIDAL BEHAVIOR?
Given that suicide/suicidal behavior occurs across psychiatric diagnoses, has familial and genetic components, and is statistically predicted by prior suicidal behavior, the question arises: should suicidal behavior be a distinct diagnostic category?
A suicidal behavior disorder diagnosis could enhance clinical focus on preventing suicide in vulnerable individuals. Current evidence suggests that patients with a history of suicidal behavior receive similar, potentially inadequate, pharmacologic treatment as other depressed patients [52].
Significant scientific data supports a suicidal behavior diagnosis, including genetic transmission, familial transmission independent of diagnosis, biological risk markers, and the predictive value of past suicidal behavior [53].
However, concerns exist that such a diagnosis could be stigmatizing and harm the doctor-patient relationship. Also, given that many suicides are first attempts [14], the added clinical assessment value might be modest. Would a separate suicidal behavior disorder diagnosis improve clinical care for suicidal patients? Such a category could aid research in detecting and treating acute suicide risk. Appropriate criteria for this disorder remain debated: prior attempts, suicide plans, rehearsals, or chronic/acute suicidal ideation?
From a clinical standpoint, the greatest need is for clinical or biological markers to detect acute suicide risk. Predicting individual behavior is inherently challenging, but any information enhancing acute high-risk state detection is invaluable for suicide prevention.
1.7. SUMMARY AND CONCLUSIONS
Suicide is a cross-diagnostic phenomenon rooted in mood depression, hopelessness, severe anxiety, and impulsivity, often linked to early abuse histories and past suicidal behavior, as well as situational factors like symptom worsening, frequently in the context of significant loss. Chronic risk factors like early childhood abuse, impulsivity, substance abuse history, living alone, and past/recent suicide attempts are crucial to identify and consider. Acute risk factors such as severe anxiety, insomnia, increased impulsivity, symptom worsening, suicide plans, and situational factors like recent major loss can prompt timely intervention. Biological trait factors like impulsivity, related to early abuse, substance abuse, and HPA, adrenergic, and serotonin system changes, appear across diagnoses. In the presence of mood depression, common across diagnoses and inherent in mood disorders, suicidal ideation can translate to attempts when combined with these factors, often triggered by adverse events or symptom exacerbation.
Further research into these pathways will deepen our clinical understanding of when and how to intervene effectively, enhancing our ability to prevent acute suicidal risk states in vulnerable individuals.
REFERENCES
1.Luoma JB, Martin CE, Oearson JL. Contact with mental health and primary care providers before suicide: A review of the evidence. Am J Psychiatry. 2002;159:908–916. [PMC free article: PMC5072576] [PubMed: 12042175]
2.Baraclough B, Bunch J, Nelson B, Sainsbury P. A hundred cases of suicide: Clinical aspects. Br J Psychiatry. 1974;125:355–373. [PubMed: 4425774]
3.Robins E. The Final Months. Oxford University Press; Oxford, U.K.: 1981. p. 47.
4.Harris EC, Baraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry. 1997;170:205–228. [PubMed: 9229027]
5.Gradus JL, Qin P, Lincoln AK, Miller M, Lawler E, Sørensen HT, Lash TL. Acute stress reaction and completed suicide. Int J Epidemiol. 2010;39:1478–1484. [PubMed: 20624822]
6.Nock MK, Hwang I, Sampson N, Kessler RC, Angermeyer M, Beautrais A, Borges G, Bromet E, Bruffaerts R, de Girolamo G, de Graaf R, Florescu S, Gureje O, Haro JM, Hu C, Huang Y, Karam EG, Kawakami N, Kovess V, Levinson D, Posada-Villa J, Sagar R, Tomov T, Viana MC, Williams DR. Cross-national analysis of the associations among mental disorders and suicidal behavior: Findings from the WHO World Mental Health Surveys. PLoS Med. 2009;6:1–17. [PMC free article: PMC2717212] [PubMed: 19668361]
7.Baldessarini RJ, Pompili M, Tondo L. Suicide in bipolar disorder: Risks and management. CNS Spectr. 2006;11:466–471. [PubMed: 16816785]
8.Brent D. What family studies teach us about suicidal behavior: Implications for research, treatment, prevention. Eur Psychiatry. 2010;25:260–263. [PubMed: 20451355]
9.Baldessarini RJ, Hennen J. Genetics of suicide: An overview. Harv Rev Psychiatry. 2004;12:1–13. [PubMed: 14965851]
10.Roy A. Family history of suicide. Arch Gen Psychiatry. 1983;40:971–974. [PubMed: 6615160]
11.Mann JJ, Bortinger J, Oquendo MA, Currier D, Li S, Brent DA. Family history of suicidal behavior and mood disorders in probands with mood disorders. Am J Psychiatry. 2005;162:1672–1679. [PubMed: 16135627]
12.Roy A. Family history of suicide and impulsivity. Arch Suicide Res. 2006;10940:347–352. [PubMed: 16920685]
13.Sarchiapone M, Carli V, Janiri L, Marchetti M, Cesaro C, Roy A. Family history of suicide and personality. Arch Suicide Res. 2009;13:178–184. [PubMed: 19363754]
14.Coryell W, Young EA. Clinical predictors of suicide in primary major depressive disorder. J Clin Psychiatry. 2005;66:412–417. [PubMed: 15816781]
15.Isometsa ET, Lonnqvist JK. Suicide attempts preceding completed suicide. Br J Psychiatry. 1998;173:531–535. [PubMed: 9926085]
16.Isometsa ET, Heikkinen ME, Marttunen MJ, Henriksson MM, Aro HM, Lönnqvist JK. The last appointment before suicide: Is suicide intent communicated? Am J Psychiatry. 1995;152:919–922. [PubMed: 7755124]
17.Busch KA, Fawcett J, Jacobs D. Clinical correlates of inpatient suicide. J Clin Psychiatry. 2003;64:14–19. [PubMed: 12590618]
18.Zhang J, Wieczorek W, Conwell Y, Tu XM, Wu BY, Xiao S, Jia C. Characteristics of young rural Chinese suicides: A psychological autopsy study. Psychol Med. 2010;40:581–589. [PMC free article: PMC2996472] [PubMed: 19656428]
19.Dumais A, Lesage AD, Alda M, Rouleau G, Dumont M, Chawky N, Roy M, Mann JJ, Benkelfat C, Turecki G. Risk factors for suicide in major depression: A case control study of impulsive and aggressive behaviors in men. Am J Psychiatry. 2005;162:116–124. [PubMed: 16263852]
20.Swann AC, Dougherty DM, Pazzaglia PJ, Pham M, Steinberg JL, Moeller FG. Increased impulsivity associated with severity of suicide attempt history in patients with bipolar disorder. Am J Psychiatry. 2005;162:1680–1687. [PubMed: 16135628]
21.Ligen MA, Zivin K, Austin KL, Bohnert AS, Czyz EK, Valenstein M, Kilbourne AM. Severe pain predicts greater likelihood of subsequent suicide. Suicide Life Threat Behav. 2010;40:597–608. [PubMed: 21198328]
22.Lofman S, Rasanen P, Hakko H. Suicide among persons with back pain: A population-based study of 2310 suicide victims in Northern Finland. Spine. 2011;36:541–548. [PubMed: 21217427]
23.Scott KM, Hwang I, Chiu WT, Kessler RC, Sampson NA, Angermeyer M, Beautrais A, Borges G, Bruffaerts R, de Graaf R, Florescu S, Fukao A, Haro JM, Hu C, Kovess V, Levinson D, Posada-Villa J, Scocco P, Nock MK. Chronic physical conditions and their association with first onset of suicidal behavior in the world mental health surveys. Psychosom Med. 2010;72:712–719. [PubMed: 20498290]
24.Kessler RC, Borges G, Walters EE. Prevalence of risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617–626. [PubMed: 10401507]
25.Fawcett J, Scheftner WA, Fogg L, Clark DC, Young MA, Hedeker D, Gibbons R. Time-related predictors of suicide in major affective disorder. Am J Psychiatry. 1990;147:1189–1194. [PubMed: 2104515]
26.Kan CK, Ho TP, Dong JY, Dunn EL. Risk factors for suicide in the immediate post-discharge period. Soc Psychiatry Psychiatr Epidemiol. 2007;42:208–214. [PubMed: 17268761]
27.Goldacre M, Seagroat V, Hawton K. Suicide after discharge from psychiatric inpatient care. Lancet. 1993;342:283–286. [PubMed: 8101307]
28.Peteet JR, Maytal G, Rokni K. Inimaginable loss: Contingent suicidal ideation in family members of oncology patients. Psychosomatics. 2010;51:166–170. [PubMed: 20332292]
29.Ahn E, Shin DW, Cho SI, Park S, Won YJ, Yun YH. Suicide rates and risk factors among Korean cancer patients, 1993–2005. Cancer Epidemiol Biomarkers Prev. 2010;19:2097–2105. [PubMed: 20696665]
30.Fang F, Keating NL, Mucci LA, Adami HO, Stampfer MJ, Valdimarsdóttir U, Fall K. Immediate risk of suicide and cardiovascular death after a prostate cancer diagnosis: Cohort study in the United States. J Natl Cancer Inst. 2010;102:307–314. [PubMed: 20124521]
31.Flensborg-Madsen T, Knop J, Mortensen EL, Becker U, Sher L, Grønbaek M. Alcohol use disorders increase the risk of completed suicide-irrespective of other psychiatric disorders. A longitudinal cohort study. Psychiatry Res. 2009;167:123–130. [PubMed: 19359047]
32.Fawcett J, Kravitz H. Anxiety syndromes and their relationship to depressive illness. J Clin Psychiatry. 1983;44:8–11. [PubMed: 6874657]
33.Clayton P, Grove WM, Coryell W. Follow-up and family study of anxious depression. Am J Psychiatry. 1991;148:1512–1517. [PubMed: 1928465]
34.Hall RC, Platt DE, Hall RC. Suicide risk assessment: A review of risk factors for suicide in 100 outpatients who make severe suicide attempts. Psychosomatics. 1999;40:18–27. [PubMed: 9989117]
35.Simon GE, Hunkeler E, Fireman B, Lee JY, Savarino J. Risk of suicide attempt and suicide death in patients treated for bipolar disorder. Bipolar Disord. 2007;9:526–530. [PubMed: 17680924]
36.Stordal E, Morken G, Mykletun A, Neckelmann D, Dahl AA. Monthly variation in rates of comorbid depression and anxiety in the general population at 63–65 degrees North: The HUNT study. J Affect Disord. 2008;106:273–278. [PubMed: 17707514]
37.Pfeiffer PN, Ganoczy D, Ilgen M, Zivin K, Valenstein M. Comorbid anxiety as a suicide risk factor among depressed veterans. Depress Anxiety. 2009;26:752–757. [PMC free article: PMC2935592] [PubMed: 19544314]
38.Brown GL, Ebert MH, Goyer PF, Jimerson DC, Klein WJ, Bunney WE, Goodwin FK. Aggression, suicide, and serotonin: Relationships to CSF amine metabolites. Am J Psychiatry. 1982;139:741–748. [PubMed: 6177256]
39.Taylor CT, Hirshfeld-Becker DR, Ostacher MJ, Chow CW, LeBeau RT, Pollack MH, Nierenberg AA, Simon NM. Anxiety is associated with impulsivity in bipolar disorder. J Anxiety Disord. 2008;22:868–876. [PubMed: 17936573]
40.Bunney WE Jr, Fawcett JA. Possibility of a biochemical test for suicidal potential: An analysis of endocrine findings prior to three suicides. Arch Gen Psychiatry. 1965;13:232–239. [PubMed: 14339278]
41.Bunney WE, Fawcett JA, Davis JM, Gifford S. Further evaluation of urinary 17-hydroxycortocosteroids in suicidal patients. Arch Gen Psychiatry. 1969;21:138–150. [PubMed: 5804011]
42.Coryell W, Schlesser MA. Suicide and the dexamethasone suppression test in unipolar depression. Am J Psychiatry. 1981;138:1120–1121. [PubMed: 7258395]
43.Targum SD, Rosen L, Capodanno AE. The dexamethasone suppression test in suicidal patients with unipolar depression. Am J Psychiatry. 1983;140:877–879. [PubMed: 6859303]
44.Yerevanian Bl, Olafsdottir H, Milanese E, Russotto J, Mallon P, Baciewicz G, Sagi E. Normalization of the dexamethasone suppression test at discharge from hospital. Its prognostic value. J Affect Disord. 1983;5:191–197. [PubMed: 6224831]
45.Jokinen J, Nordström AL, Nordström P. CSF 5-HIAA and DST non-suppressionorthogonal biologic risk factors for suicide in male mood disorder inpatients. Psychiatry Res. 2009;165:96–102. [PubMed: 19062105]
46.Coryell W, Schlesser M. Combined biological tests for suicide prediction. Psychiatry Res. 2007;150:187–191. [PMC free article: PMC1880882] [PubMed: 17289156]
47.Sachar EJ, Kanter SS, Buie D, Engle R, Mehlman R. Psychoendocrinology of ego disintegration. Am J Psychiatry. 1970;126:1067–1068. [PubMed: 5411360]
48.Fava M, Alpert JE, Carmin CN, Wisniewski SR, Trivedi MH, Biggs MM, Shores-Wilson K, Morgan D, Schwartz T, Balasubramani GK, Rush AJ. Clinical correlates and symptom patterns or anxious depression among patients with major depressive disorder in STAR*D. Psychol Med. 2004;34:1299–1308. [PubMed: 15697056]
49.Fava M, Rush AJ, Alpert JE, Carmin CN, Balasubramani GK, Wisniewski SR, Trivedi MH, Biggs MM, Shores-Wilson K. What clinical and symptom features and comorbid disorders characterize outpatients with anxious major depressive disorder: A replication and extension. Can J Psychiatry. 2006;51:823–835. [PubMed: 17195602]
50.Coryell W, Solomon DA, Fiedorowicz JG, Endicott J, Schettler PJ, Judd LL. Anxiety and outcome in bipolar disorder. Am J Psychiatry. 2009;166:1238–1243. [PMC free article: PMC3551283] [PubMed: 19797434]
51.Coryell W, Fiedorowicz JG, Solomon D, Leon AC, Rice JP, Keller MB. Effects of anxiety on the long-term course of depressive disorders. Br J Psychiatry. 2012;200:210–215. [PMC free article: PMC3290796] [PubMed: 21984801]
52.Oquendo MA, Kamali M, Ellis SP, Grunebaum MF, Malone KM, Brodsky BS, Sackeim HA, Mann JJ. Adequacy of antidepressant treatment after discharge and the occurrence of suicidal acts in major depression: A prospective study. Am J Psychiatry. 2002;159:1746–1751. [PubMed: 12359682]
53.Oquendo MA, Baca-Garcia E, Mann JJ, Giner J. Issues for DSM-V: Suicidal behavior as a separate diagnosis on a separate axis. Am J Psychiatry. 2008;165:1383–1384. [PMC free article: PMC3776420] [PubMed: 18981069]
