Suicide, Risk Evaluation

Basics

Description

  • Suicide: Intentionally taking one’s own life
  • Suicidal ideation: Thoughts about ending one’s own life, with or without a clear plan for suicide:
    • Passive suicidal ideation: A conscious desire not to live, without plan or intent
    • Active suicidal ideation: Thoughts of ending one’s life, with or without a plan
  • Nonsuicidal self-injury or parasuicidal behavior: Self-injury not intended to cause death (eg, superficial cutting, cigarette burns, head banging)
  • Reckless behavior: Medication misuse, dangerous actions
  • Risk-to-rescue: Ratio of lethality of plan compared with likelihood of rescue:
    • High risk-to-rescue ratio indicates increased severity of attempt
  • Occult presentations:
    • Many at-risk patients present to the ED with nonpsychiatric complaints weeks before a suicide attempt, emphasizing the need for improved suicide risk screening

Etiology

  • Suicide is a complex, neurobehavioral phenomenon with multifactorial etiology; psychological, social, environmental, and genetic factors all interact to bring a person to this point

Epidemiology

  • Suicide attempts increased 20% in the last decade, now making up ∼2% of ED visits, varying by location
  • In 2021, 48,183 suicides and 1.5 million attempts occurred, with men at higher risk than women
  • Firearms (50%), suffocation, and poisoning are the most common means of suicide deaths in the US

Epidemiologic Risk Factors

  • Women attempt suicide more often than men but use less lethal methods:
    • Higher risk in youth and postpartum
    • Mood disorders, abuse history, and relationship stressors elevate suicide risk
  • Men die by suicide at rates 3–4 times higher than women:
    • Firearms are the most common means, used in >50% of male suicides
    • Suicide rates per capita peak in older men (75+ yr old), the highest risk demographic
  • Age:
    • Adolescents and young adults have the highest suicide attempt rates
    • Middle-aged men account for the highest total number of suicides
    • Older adults have fewer attempts but higher completion rates:
      • Completed suicide: 83% men
      • Risk factors: Divorced, widowed, male, social isolation
  • 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 (eg, physicians)
  • Access to firearms

Pediatric Considerations

  • Suicide is the 2nd leading cause of death among young people 10–24 yr of age; risk in this group increased over 50% since 2000
  • About 7000 adolescents commit suicide every year in the US (CDC, 2021)
  • Rapidly increasing in young black males aged 10–14
  • Less evidence linking suicide in youth to overt psychiatric illness
  • Consider and screen for bullying
  • Stresses:
    • Academic or social problems at school
    • Family disruption
    • History of psychiatric disorder
    • Depression
    • Disciplinary crisis
    • Relationship problems
    • Bereavement
    • Rejection
    • History of physical or sexual abuse
  • Early warning signs:
    • Progressively declining schoolwork
    • Multiple physical complaints
    • Increased substance use
    • Disrupted family relations
    • Social withdrawal
    • Anhedonia

Diagnoses Associated With Completed Suicide

  • >90% of patients who complete 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

  • Recently discharged from psychiatric facility
  • Recent medical visit to general practitioner or PCP
  • Veterans
  • History of suicidal ideation or suicide attempt
  • Family history of suicide attempt/completion
  • History of incarceration
  • Unstable housing, and social isolation
  • Victims of violence/abuse

Interventions That Lower Risk

  • Reducing access to lethal means
  • 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, no-suicide contracts

Protective Factors

  • Strong social supports
  • Family cohesion
  • Peer group affiliation (eg, religion, employment, volunteering)
  • Good coping and problem-solving skills
  • Ability to seek and access help

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