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Suicidality and Violence in
Patients With HIV/AIDS
http://www.hivguidelines.org/GuideLine.aspx?pageID=261&guideLineID=84
Updated January 2007
I. INTRODUCTION
Recommendations:
Clinicians should clearly instruct medical support staff about
how to manage emergencies involving patients with suicidal or
violent behavior, such as contacting emergency services or
isolating the patient from other patients.
Clinicians should obtain an emergency evaluation if they
determine that a patient is at imminent risk of harm to self or
others. Patients who are not at immediate risk should be
referred to outpatient mental health services when the mental
health treatment by the primary care clinician does not result
in successful stabilization of symptoms.
Clinicians should assess HIV-infected patients for depression to
ensure early detection and treatment of patients who may be at
increased risk of suicide due to depressive symptoms.
HIV-infected patients may be at higher risk for suicidal
behavior, particularly after a diagnosis of HIV disease or
during progression to AIDS, as patients’ health and quality of
life decline.1-4 Other patients, such as those with certain
personality disorders, may be at increased risk for violent
behavior.5 Although only a small number of HIV-infected patients
attempt or commit suicide or violence, routine mental health
assessment and procedures in the clinic setting for responding
to mental health emergencies can ensure that the potential for
such behavior is identified and appropriately addressed.
Key Point:
A significant percentage of patients who commit suicide will
have seen their primary care clinician in the month before their
suicide. This underscores the importance of routine mental
health screening in the primary care setting, which can help
identify patients who are at risk for suicide and enable them to
receive treatment for the underlying cause of their suicidal
behavior.
This chapter discusses suicidal and violent behavior,
self-injurious behavior, and the desire for hastened death.
Suicidal behavior is defined as suicidal ideation; suicide
attempts; deliberate self-harm, with or without suicidal intent;
or completed suicide. Violence is defined as the threatened or
actual use of physical force against another person with the
intent to cause harm.
II. PREVALENCE AND RISK OF SUICIDE AND VIOLENCE
A. Suicide
Rates of suicidal behavior have been more widely studied in gay
men than in other populations,6 although some studies have shown
that HIV-infected women have higher rates of suicide attempts
than HIV-infected men.7,8 Studies conducted before the
introduction of HAART indicated an increased risk of completed
suicide in patients with HIV/AIDS that was 7 to 36 times greater
than in the non-HIV-infected population.9,10 Since the
introduction of HAART, more recent evidence suggests that
suicide among HIV-infected patients may be mediated more often
by factors other than HIV, including depression, alcohol, or
other substance-related disorders. Because patients with
suicidal behavior often present with comorbid depression,
screening for and timely treatment of depression may reduce a
patient’s risk for suicide. For information regarding depression
among HIV-infected patients, see Depression and Mania in
Patients With HIV/AIDS.
Suicide risk in HIV-infected patients may be higher than in
populations with other chronic medical illnesses, such as
cancer.11 Evidence suggests that risk for suicidal behavior
increases during the initial weeks following a diagnosis of HIV
disease and then declines as patients adjust to their HIV
status.1,2 However, as patients’ health and quality of life
decline, risk of suicide may again increase,3,4 particularly
among middle-aged and older patients, who frequently experience
poorer health-related quality of life when progressing to AIDS.3
B. Violence
No documented studies have established increased rates of
violence among HIV-infected individuals compared with
noninfected individuals or those of unknown HIV status. However,
studies indicate that certain personality disorders that are
defined by impulsive or aggressive features, such as borderline
and antisocial personality disorders, are more prevalent in
certain groups of HIV-infected individuals, specifically
intravenous drug users, compared with the general population.5
Symptoms such as perceptual disturbances and mood instability
may account for an increased risk of violence.
Key Point:
The combination of mental health and substance use disorders
places people at the greatest risk for violence.12
III. ASSESSMENT OF SUICIDAL AND VIOLENT BEHAVIOR
A comprehensive mental health assessment is essential for any
patient who directly expresses suicidal or violent behavior or
whose behavior and risk factors suggest potential for suicide or
violence. Figure 1 provides an algorithm for assessing and
managing suicidal or violent patients.
A. Detection of Suicidal and Violent Behavior
Recommendation:
Clinicians should assess for suicidal and violent behavior at
baseline and at least annually as part of the mental health
assessment (see Figure 1).
For many clinicians, questions about suicide and violence are
difficult to ask. Some clinicians may be unsure of how to
respond to a patient who expresses potential for suicide or
violence. For example, a clinician in a busy clinic setting may
think, I have 10 people in my waiting room. What do I do now?
The clinician may also feel that asking about suicide or
violence might provoke suicidal or violent thoughts in patients
or disrupt the clinician-patient relationship. However, when a
patient recognizes concern and empathy in the clinician’s
lead-in questions, assessing risk of suicide or violence may
actually strengthen the clinician-patient relationship. For
example, It sounds as if you are in great pain. Have you ever
thought life was not worth living? or You sound as if you feel
very angry and frustrated at home. Do you ever have the impulse
to physically harm your partner or has the conflict between the
two of you ever become violent?
B. Estimation of Risk for Suicide or Violence
Recommendation:
Clinicians should assess patients who have expressed thoughts of
suicide or violence for specific risk factors that indicate
suicidal or violent intent and for impaired impulse control (see
Tables 1 and 2).
Once a patient acknowledges that he/she has considered harming
himself/herself or others, clinicians should ask about planned
intent and risk factors. Risk factors for suicide and violence
are illustrated in Table 1. The more risk factors a patient has,
the greater the likelihood of suicide and violence. Although no
study has indicated that one risk factor or set of risk factors
is more predictive of suicidal behavior than others, most
studies suggest that the best predictor of future violence is a
history of past violence.
Table 1: Risk Factors for Suicide and Violence
Adapted, with permission, from Cournos F, Cabaniss D. Clinical
evaluation and treatment planning: A Multimodal Approach. In:
Psychiatry, Second Edition. (Tasman A, Kay J, Lieberman J, eds).
Chichester, England: John Wiley and Sons Ltd.; 2003.
* This distinction between male and female suicidal behavior may
not apply to gay and lesbian youth, who may be at increased risk
for suicide attempts associated with experience of harassment,
homophobia, gender nonconformity, and disclosure of sexual
identity.
† In some cases, patients who are depressed may have family or
friends who are supportive, but the patients do not perceive
them as being supportive.
Questions that ask directly about suicidal or violent thoughts
are essential during assessment of the patient’s level of
potential danger. For example, questions such as, Do you often
think about hurting yourself or someone else?...How might you do
that?...You know, there is a big difference between having those
thoughts and acting on them. Is this something you might
actually do? may help determine the degree of harm.
Key Point:
People who lack adequate impulse control may represent a serious
risk despite stated wishes not to harm themselves or others.
Patients may describe thoughts of harming themselves or others,
yet deny intent to act on these thoughts. Therefore, an
assessment of impulsivity is an important aspect of estimating
risk for suicide and/or violence. During interactions with
patients, clinicians may notice behaviors that suggest impaired
impulse control. For example, patients may suddenly and
unexpectedly become verbally aggressive and threatening while
discussing a recent life change, such as a job loss. Other
patients may initiate a discussion about a significant event,
such as a recent break-up with a partner, and then abruptly and
prematurely decide to end the conversation or leave because of
feelings of hopelessness. Neither of these situations alone
would indicate serious risk of suicide. However, either
situation in combination with other risk factors (see Table 2)
should heighten concern about a patient’s potential for suicide.
IV. MANAGEMENT AND REFERRAL OF SUICIDAL AND VIOLENT PATIENTS
Recommendations:
Clinicians should maintain an up-to-date list of easily
accessible mental health referral resources for patients who
require either immediate mental health assessment or for whom
assessment is less urgent.
Clinicians should attempt to involve people whom the patient
perceives as supportive, such as friends and family, in
treatment planning and management.
The management and referral strategies for suicidal and
potentially violent patients depend on multiple factors,
including the presence of risk factors, whether the risk factors
indicate imminent danger, and acute versus chronic nature of
suicidal or violent thoughts. Patients who present an imminent
risk of harm to self or others represent a psychiatric
emergency. Patients who are not imminently dangerous, but
present with multiple risk factors and fail to respond to mental
health treatment by the primary care clinician, require a
complete evaluation by a mental health provider. Social support
and referral to outpatient mental health services may also be
necessary.
Key Point:
Social support is fundamental to effective management of
suicidal and potentially violent patients and can enable
patients to accept help. Sources of support may include
involvement of family, friends, or community-based services and
the clinician’s interest in understanding reasons for patients’
wishes to harm themselves or others.
Involvement of people whom the patient perceives as supportive,
such as friends and family, is essential for effective
management of suicidal and potentially violent patients. For
example, a patient who is not at immediate risk for suicide or
violence might feel safer staying with a friend until he/she can
see a psychiatrist for evaluation.
A. Imminent Suicidal or Violent Potential
Recommendation:
The clinician, or a member of the health care team, should
escort a patient to the emergency department or call 911 when
the patient expresses suicidal or violent thoughts accompanied
by risk factors that indicate imminent danger (see Figure 1).
A patient who expresses actual intent to commit suicide or harm
others needs urgent intervention and should receive immediate
emergency department mental health assessment. A clinician’s
assessment that a patient is in imminent risk of harm to self or
others overrules the patient’s right to refuse treatment. In
these cases, the clinician may need to call emergency services
or the police.
New York State mental health laws provide legal procedures for
the management of patients who are imminently suicidal and/or
violent. Patients may be held against their will, for up to 72
hours, while a mental health assessment is performed to
determine a patient’s risk of harming self or others. If a
mental health assessment, usually involving two psychiatrists,
determines that a patient is at risk for suicide or violence,
that person may be confined involuntarily beyond 72 hours for
the purposes of mental health treatment. The clinician may also
deem it necessary to warn any intended victim(s) of the
violence. In this case, the clinician is permitted to overrule
the patient’s privacy privilege.
B. Non-imminent Suicidal or Violent Potential With Accompanying
Risk Factors
Recommendations:
Clinicians should refer patients who express suicidal or violent
thoughts, but who are not at imminent risk, for a complete
mental health evaluation when the mental health treatment by the
primary care clinician does not result in successful
stabilization of symptoms (see Figure 1).
Clinicians should discuss with patients the reasons why they
think about suicide or violence and should develop a plan to
modify risk factors.
Patients with serious suicidal and/or violent thoughts who are
not imminently dangerous, but who possess risk factors, may be
helped through modification of the risk factors listed in Table
1. The following are examples for addressing risk factors:
• Treatment of underlying mental health disorder, particularly
depression
• Reduction of social isolation
• Alleviation of physical pain, physical impairments, sleep
disturbance
• Removal of access to means of suicide or violence, such as
medications and guns
Key Point:
Patients with chronic suicidal and/or violent ideation often
require long-term psychiatric treatment.
Suicidal thoughts can be amplified by HIV infection,
particularly when suicide is consciously or unconsciously
suggested to the patient by loved ones who cannot cope with the
consequences of HIV/AIDS. Family, friends, and even healthcare
workers who identify with a patient’s hopelessness may further
exacerbate suicidal thoughts by expressing ideas such as, Well,
I might try to kill myself under these circumstances too. Rather
than accept or reinforce such ideas, clinicians should explore
with patients the reasons why they think about suicide or
violence and explore means to modify risk factors. For example,
a patient may fear physical pain and suffering, so a discussion
of the treatment of the pain may markedly diminish the suicide
potential.
C. Chronic Suicidal or Violent Ideation
Recommendation:
Clinicians should refer patients who express chronic wishes to
harm self or others for a comprehensive outpatient mental health
evaluation and then maintain ongoing communication with the
mental health provider(s) involved in the patients’ mental
health care.
Some patients present with longstanding suicidal and/or violent
thoughts that remain constant, although the thoughts may
fluctuate in intensity over time. The level of risk may be less
easily modified in the short term than among patients with more
acute symptoms. Patients with chronic suicidal or violent
ideation often require long-term psychiatric management.
Treatment is usually designed to address underlying factors
associated with their suicidal and/or violent thoughts (see
Table 3). It is also important to recognize that patients with
chronic suicidal and/or violent ideation may experience periods
of acute worsening of symptoms that require a more aggressive
treatment approach. For example, a patient with chronic suicidal
and/or violent ideation who relapses to using alcohol or other
drugs may require emergency evaluation. Similarly, increased
suicidal ideation in a chronically suicidal patient may reflect
new-onset depression that can be alleviated by treatment.
Table 3: Management Strategies for Chronic Suicidal and/or
Violent Ideation
Type of Chronic Ideation Description Management Strategy
Chronic suicidal and/or violent ideation resulting from mental
health disorders May be a feature of personality disorders, such
as borderline or antisocial personality disorder, or a feature
of chronic mental health disorder, such as schizophrenia. These
patients usually require close coordination of treatment and
communication between the primary care clinician and the mental
health provider. Inpatient psychiatric hospitalization may be
necessary during periods of acute crises.
Chronic suicidal ideation as a coping strategy May be a coping
strategy for patients with chronic medical illness. For these
patients, thinking about suicide may be an unconscious attempt
to regain a sense of control over their lives. Patients may say
or think, Well, if things get too overwhelming, I can always
kill myself. Such thoughts may lend some sense of control to
patients by providing a future option that never has to be acted
on. When no other risk factors are present, most patients who
express this type of suicidal thinking do not act on it. During
acute crises or when other risk factors are present, these
patients may be at more significant risk for suicide and require
mental health assessment or inpatient hospitalization.
Chronic suicidal ideation among patients with desire for
hastened death Some patients, usually those with more advanced
disease, may request that their clinicians assist them in either
suicide or hastened death. Additionally, some patients may wish
to hasten their own deaths by refusing treatment. These patients
may be suffering from a reversible mental health disorder, most
notably depression, which could contribute to their wish to die.
A mental health assessment should be performed to address any
correctable problems, such as depression and poorly controlled
anxiety, pain, or delirium.
Chronic suicidal ideation among self-injurious patients Patients
may also present with chronic and repetitive self-injurious
behaviors, such as cutting, that may or may not be associated
with suicidal intent. These behaviors are more likely to occur
in patients with borderline and antisocial personality
disorders. In these patients, self-inflicted injury may be an
expression of anger or frustration and serves to relieve
internal tension. They may feel better after injuring
themselves. These patients may benefit from ongoing specialized
outpatient mental health treatment. They may also require brief
mental health inpatient hospitalizations during crisis periods,
when suicidal potential is heightened. See Personality Disorders
in Patients With HIV/AIDS.
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FURTHER READING
Cohen MA, Gorman JM, eds. Comprehensive Textbook of AIDS
Psychiatry. New York: Oxford University Press; 2008.
Fazel S, Grann M. Psychiatric morbidity among homicide
offenders: a Swedish population study. Am J Psychiatry
2004;161:2129-2131.
Fernandez F, Ruiz P, eds. Psychiatric Aspects of HIV/AIDS. 1st
ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
Marzuk PM, Tardiff K, Leon AC, et al. HIV seroprevalence among
suicide victims in New York City, 1991-1993. Am J Psychiatry
1997;154:1720-1725.
Organization of AIDS Psychiatry. Bethesda, MD: Academy of
Psychosomatic Medicine. Available at: www.apm.org/sigs/oap
Perry S, Jacobsberg L, Fishman B: Suicidal ideation and HIV
testing. JAMA 1990;263:679-682.
Practice guideline for the assessment and treatment of patients
with suicidal behaviors. Am J Psychiatry 2003;160:(Suppl
11):1-60.
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