Suicide, Risk Evaluation

Description

• Intentionally taking one's own life
• Suicidal ideation:
  • Passive: A conscious desire not to live
  • Active: Intention to take one's life, with or without a plan
• Parasuicidal behavior: Self-injury not intended to cause death (e.g., superficial cutting, cigarette burns, head banging)
• Reckless behavior: Not taking prescribed medications, taking too much of prescribed medications, running into traffic
• Risk-to-rescue ratio – lethality of plan compared with likelihood of rescue:
  • High risk-to-rescue ratio indicates increased severity of attempt
• Occult presentation:
  • Many individuals at risk for suicidal behavior seek care in the ED for medical and not behavioral complaints
  • Improved suicide screening practices may be needed to capture this population

Etiology

• 42,826 suicides in the U.S. in 2014 (CDC 2014)
• 12–25 attempts per completed suicide
• 20.7 completed suicides per 100,000 males (CDC 2014)
• 5.8 completed suicides per 100,000 females (CDC 2014)
• 13.4 completed suicides per 100,000 general population (CDC 2014)
• 21,386 deaths per 100,000
• Suffocation (11,407 deaths per 100,000)
• Poisoning (6,808 deaths per 100,000)
• Others: Hanging, jumping

• Gender:
  • Women 3× more likely to attempt suicide
  • Men 3× more likely to complete suicide
• Age
• Ethnicity: White or Native American
• Marital status: Widowed or divorced
• Living alone: No children in the home
• Employment: Unemployed, work-related access to lethal means (e.g., physicians)
• Access to firearms

• >90% of patients who commit suicide have a psychiatric diagnosis and >50% are depressed at the time of the attempt
• Depression (especially depression with psychotic features or bipolar depression)
• Anxiety disorders (especially panic disorder)
• Substance use disorders (especially alcohol)
• Schizophrenia
• Chronic medical illness (especially traumatic brain injuries, epilepsy, multiple sclerosis, Huntington disease, Parkinson disease, cancer, HIV/AIDS)

• Recent discharge from psychiatric facility
• Recent medical visit to general practitioner or PCP
• History of suicidal ideation or suicide attempt
• Family history of suicide attempt/completion
• History of incarceration
• Marginalized individuals (e.g., homeless, unemployed, socially isolated)
• Victims of violence/abuse

• Enhancing a well-defined support network including wrap-around care teams of PCP, behavioral health, social services, and case management
• Patients with mood disorders (major depression and bipolar disorder) treated with lithium
• Patient with major depression treated with electroconvulsive therapy
• Patients with schizophrenia treated with clozapine
• Emerging research suggests ketamine may reduce suicidality but further research is needed
• NOT shown to decrease suicide rates: Treatment with selective serotonin reuptake inhibitors (SSRIs) for major depression

• Strong social supports
• Family cohesion
• Peer group affiliation (e.g., religion, employment, volunteering)
• Good coping and problem-solving skills
• Positive values and beliefs
• Ability to seek and access help