Suicide, Risk Evaluation

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  • 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.


  • 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)

Risk Factors for Suicidal Behavior
  • 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

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

Methods of Suicide (CDC 2009)
  • 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

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

Others at Risk for Completing Suicide
  • 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

Interventions that Lower Risk
  • 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

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

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