Suicide, Risk Evaluation

Basics

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

Epidemiologic Risk Factors
  • 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

Diagnoses Associated with Completed Suicide
  • >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)

Others at Risk for Completing Suicide
  • 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

Interventions That Lower Risk
  • 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

Protective Factors
  • 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

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