Suicide, Risk Evaluation

Description

• The intentional taking of one's own life
• Suicidal ideation:
  • Passive: A conscious desire not to live
  • Active: Intention to die 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 nonbehavioral complaints
  • Improved suicide screening practices may be needed to capture this population.

Etiology

• 36,891 suicides in US (CDC 2009)
• 12–25 attempts per every completed suicide
• 25.4 per 100,000 males (CDC 2009)
• 7.4 per 100,000 females
• 11.1 per 100,000 general population
• 2 peaks in age group most at risk for suicide:
  • Age 15–24 yr (3rd leading cause of death in this age group)
  • Age >60 yr (highest rates of any age group, increasing incidence with age)

• Depression (bipolar or unipolar)
• Alcohol or drug abuse
• History of physical or sexual abuse
• Unemployment
• Incarceration
• History of head injury or neurologic disorder
• Firearms in the home
• Cigarette smoking
• Positive family history of suicide attempt
• Psychiatric or medical comorbidities
• Gender:
  • Women 3 times more likely to attempt suicide.
  • Men 3 times more likely to complete suicide.
• Psychological:
  • Impulsivity/aggression
  • Depression
  • Anxiety
  • Hopelessness
  • Self-consciousness/social disengagement
  • Poor problem-solving abilities
  • Lack of social supports
  • Widowed
  • Divorced
  • Separated
  • Lack of social supports
  • Recent loss of relationship
  • Anniversary of loss
• Environmental
• Rural areas:
  • Access to firearms
  • Poverty
  • Unemployment

• Male
• Age >60 yr
• White or Native American
• Widowed/divorced
• Living alone
• Unemployment/poverty
• Past suicide attempt

• Firearms (most common among men and 2nd most common in women)
• Overdose (Most common among women); most common means of suicide attempt (70% of failed attempts are by overdose)
• Hanging
• Suffocation

• >90% of patients who commit suicide have a psychiatric diagnosis.
• Depression—especially psychotic depression
• Anxiety and panic disorder
• Alcohol or drug intoxication
• Schizophrenia
• Adolescents

• Recent discharge from psychiatric facility
• History of suicidal ideation or suicide attempt
• Serious physical illness present in up to 70% of all suicides, particularly in elderly patients.
• History of incarceration
• Physicians
• Victims of violence/abuse

• 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
• NOT shown to decrease suicide rates: Treatment with selective serotonin reuptake inhibitors (SSRIs) for major depression

• Strong social supports
• Family cohesion
• Peer group affiliation
• Good coping and problem-solving skills
• Positive values and beliefs
• Ability to seek and access help