Suicide 

Suicide ranks as the tenth leading cause of death in the United States (see the chart below).^{[1, 2]} Globally, an estimated 700,000 people take their own lives annually.^[3] In certain populations, such as adolescents and young adults, suicide constitutes 1 of the top 3 causes of death. This phenomenon is even more compelling because, in many instances, suicides can be prevented. Therefore, clinicians must recognize the risk factors for suicide as a way of intervening in a self-destructive event and cycle.

This article discusses the following:

• Basic terminology applied to self-destructive activities and events
• Risk factors that can alert the clinician to early warning signs of suicide
• Interventions if a person's attempt at suicide is imminent
• The diagnosis and treatment of the underlying mental disorder causing the self-destructive behavior
• Appropriate actions for a clinician if a person being treated does commit suicide

Depression, isolation, previous suicide attempts, substance abuse, and serious mental illness rank as highly significant contributors to suicide. Swift and decisive interventions based on a thorough assessment can save lives. Preventing a person from committing suicide, however, is only the first step in the treatment of the suicidal patient.

Diagnostic and treatment considerations

Once it has been assured that the patient is safe, the reasons for the individual’s self-destructive behavior must be found. The diagnosis requires a complete psychiatric history and mental status examination. (See the chart below.)

The choice of treatment is dictated by the specific mental illness affecting the patient. Talking therapies can help, and in many instances, medication can alleviate symptoms of mental illness. Finally, however, despite intervention, if the patient does commit suicide, a number of steps can and should be undertaken for the patient's family, other patients, the staff, and the therapist.

Terminology

Suicide means killing oneself. The act constitutes a person willingly, perhaps ambivalently, taking his or her own life. Several forms of suicidal behavior fall within the self-destructive spectrum.

A completed suicide means the person has died. It is important not to use the term successful suicide; the goal is to prevent suicide and provide treatment.

A suicide attempt involves a serious act, such as taking a fatal amount of medication and someone intervening accidentally. Without the accidental discovery, the individual would be dead.

A suicide gesture denotes a person undertaking an unusual, but not fatal, behavior as a cry for help or to get attention.

A suicide gamble is one in which patients gamble their lives that they will be found in time and that the discoverer will save them. For example, an individual ingests a fatal amount of drugs with the belief that family members will be home before death occurs.

A suicide equivalent involves a situation in which the person does not attempt suicide. Instead, he or she uses behavior to get some of the reactions that suicide would have caused. For example, an adolescent boy runs away from home, wanting to see how his parents respond. (Do they care? Are they sorry for the way that they have been treating him?) The action can be seen as an indirect cry for help.

A number of factors correlate with serious suicide attempts and completed suicides, including, but not limited to, the following:

• Medications
• Mental illness
• Sex
• Genetics
• Availability of firearms
• Life experiences
• Physical illness
• Economic instability and status
• Media and the Internet
• Psychodynamic formulation

An understanding of the causes of suicidal behavior will not only clarify the roots of the patient’s self-destructive path but also help the clinician to determine the appropriate treatment for the patient. Once the patient is safe, then the underlying dynamics can be addressed.

Medications

A number of medications have been linked to suicidal behavior, which has prompted the US Food and Drug Administration (FDA) to require a warning on certain prescription drugs, including antidepressants, anticonvulsants, and analgesics.

Antidepressants

Initially, the FDA and studies linked antidepressants to childhood and adolescent self-destructive events and required a warning for those populations; however, Schneeweiss and colleagues found the same linkage for adults as well.^[4]

The investigators reviewed data from all 287,543 residents of Canada's British Columbia, 18 years or older, who had been placed on an antidepressant between 1997 and 2005 and concluded the following: "Our finding of equal event rates across antidepressant agents supports the US Food and Drug Administration's decision to treat all antidepressants alike in their advisory. Treatment decisions should be based on efficacy, and clinicians should be vigilant in monitoring after initiating therapy with any antidepressant agent."^[4]

Anticonvulsants

In 2008, the FDA required a suicidal behavior warning be placed on anticonvulsants. In a 2010 exploratory analysis, Patorno and colleagues suggested that the use of gabapentin, lamotrigine, oxcarbazepine, and tiagabine, compared with the use of topiramate, may be associated with an increased risk of suicidal acts or violent deaths.^[5]

Pain medication

Tramadol is a narcoticlike pain reliever that, on May 26, 2010, received an FDA addition of a suicide risk warning (tramadol hydrochloride [Ultram] and tramadol hydrochloride/acetaminophen [Ultracet]).^[6] The FDA noted linkage between tramadol prescriptions and patients with emotional instability and suicidal ideation and increased self-destructive behavior.^[6]

Smoking cessation medications

Moore et al determined that the risk of depression and suicidal or self-injurious behaviors is substantially increased and statistically significant with the use of varenicline. Risk was also present, but smaller, with bupropion, and was even smaller with nicotine replacement. The investigators suggested that varenicline is unsuitable as a first-line agent to aid in smoking cessation.^[7]

Glucocorticoids

A study by Fardet et al concluded that glucocorticoids increase the risk of suicidal behavior and neuropsychiatric disorders. The authors reviewed data from all adult patients in UK general practices from 1990 to 2008. Of 786,868 courses of oral glucocorticoids prescribed for 372,696 patients, there were 109 incident cases of suicide or suicide attempt and 10,220 incident cases of severe neuropsychiatric disorders.^[8]

Mental illness

Although mental illness is generally linked to premature deaths, certain mental illnesses carry with them remarkably high lifetime instances of suicide. In fact, 95% of people who commit suicide have a mental illness. In a general sense, mental illness all too often is an isolating experience, with such isolation correlating with suicide.

Hospitalization for a psychiatric disorder is quite prevalent in the suicidal population,^[9] including for people with any depressive disorder, bipolar disorder, schizophrenia, posttraumatic stress disorder (PTSD), phobias, substance abuse problems, delirium, and dementia, as well as certain genetic factors.

Each psychiatric disorder has its own distinctive mental status footprint. A mental status review is designed to help evaluate a person’s suicide potential.

The following list represents some of the mental disorders frequently associated with suicidal behavior, but self-destructive thoughts and acts also may occur in other diagnoses:

• Alcoholism
• Anxiety disorders
• Bipolar affective disorder
• Bulimia nervosa
• Cocaine-related psychiatric disorders
• Delirium
• Depression
• Dysthymic disorder
• Hallucinogens
• Obsessive-compulsive disorder
• Opioid abuse
• Pediatric depression
• Personality disorders
• Postpartum depression
• PTSD
• Schizophrenia
• Seasonal affective disorder
• Social phobia
• Vascular dementia

Depression

Because depression involves a preoccupation with death, the twin killers of hopelessness and helplessness, and withdrawal, it is a major contributor to suicide. A dangerous time in depression occurs when a patient is coming out of the deepest part of the experience. At that point, the individual may mobilize his or her newly acquired energy to commit suicide.

The protracted and profound emotional roller coaster of manic-depressive illness puts a patient at risk both during the depressive phase and in the psychosis of mania. Suicide is a particular risk when executive functions and judgment have been compromised by bipolar disorder.^[10] In particular, men with bipolar disorder have an increased risk for suicide.^[11]

One important consideration in the treatment of depression is that selective serotonin reuptake inhibitors (SSRIs) have a lower rate of fatal overdoses than do tricyclic antidepressants (TCAs).^[12]

Shah et al found that in adults younger than 40 years, depression and history of attempted suicide are significant independent predictors of premature cardiovascular disease and ischemic heart disease in males and females.^[13]

Schizophrenia

Schizophrenic patients are at a significantly high risk for suicide. They may experience hallucinations, often auditory, such as voices commanding them to kill themselves (command hallucinations). In addition, these individuals may, in the context and as a result of their illness, become depressed; they realize that they are different from others.

Persons with schizophrenia may also have moments of insight during which they realize that they may not achieve some life goals that others can accomplish. Individuals who are considered highly functional seem to be at high risk for suicide, perhaps because of their ability to appreciate how they are different from others and how their life is different from what they wish it to be.

Finally, the suspicions and fears associated with schizophrenia may promote isolation and withdrawal.

The high rate of suicide in patients with schizophrenia is higher when physical comorbidity or substance abuse is also present.^[14]

Anxiety disorders

Obsessive-compulsive disorder (OCD) and phobic disorders have symptoms that make suicide a possibility. Persons struggling with these symptoms feel frightened, terrorized, isolated, and physically paralyzed by feelings of anxiety, panic, and dread that often seem inexplicable. In many instances, people feel that the symptoms are growing, expanding, and becoming incapacitating.

A study by Katz et al showed that panic attacks and panic symptoms in individuals with a major mood disorder meeting criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), may carry an increased risk of suicidal ideation. This ideation may progress to suicide attempts, especially in individuals with prominent catastrophic cognitions.^[15] An example would be a woman with agoraphobia who becomes progressively more isolated and depressed by her inability to leave her home.

Posttraumatic stress disorder

Survivors of trauma (eg, childhood sexual abuse, recent physical devastation, physical/emotional abuse) struggle with flashbacks and nightmares. These individuals frequently alternate between periods of hypervigilance and periods of psychic numbing.

Veterans of the wars in Iraq and Afghanistan experience a high rate of PTSD—with many struggling with feelings of being damaged and with feelings of guilt—and have a historically high rate of suicide.^{[16, 17, 18]}

Postdeployment readjustment problems affecting veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) are well documented, but the possible relationship of readjustment stressors to the increase in military suicides is not.

Kline et al found that after adjusting for mental health and combat exposure, veterans with the highest number of readjustment stressors had a 5.5 times greater risk of suicidal ideation than those with no stressors. This suggests that suicide prevention efforts that more directly target readjustment problems in returning OEF/OIF veterans are needed.^[19]

Substance abuse

Substances can contribute to self-destructive behaviors in all 3 phases of their use—intoxication, withdrawal, and chronic usage. A depressed person commonly becomes acutely suicidal after a few drinks. Similarly, some people can become suicidal after ingesting lysergic acid diethylamide (LSD). Still others encounter depression during substance withdrawal and respond by killing themselves. (See the graph below.)

A person who engages in chronic alcohol and drug use often experiences a number of major losses, including of his or her job, spouse, and family, and these, in turn, contribute to the individual becoming suicidal.^[11]

Even persons in drug recovery programs remain at risk. For example, patients in opiate dependency programs, especially those with chronic pain, those with the availability of firearms, those who use other street drugs, and those new to the program, are at particular risk.^[20]

In a US study, Bohnert et al found that suicide and overdose are connected, yet distinct, problems. Patients who have a history both of suicide attempts and of nonfatal overdoses may have poor psychological functioning, as well as a more severe drug problem.^[21]

The physical and mental health effects associated with methamphetamine (MA) use have been documented; however, little is known about the effects of injection MA and suicidal behavior.

The Vancouver Injection Drug Users Study (VIDUS) found that MA injection was associated with an 80% increase in the risk of attempted suicide, suggesting that individuals who inject MA should be monitored for suicidal behavior. The study elicited information regarding sociodemographics, drug use patterns, and mental health problems, including suicidal behavior. Of 1873 eligible participants, 149 (8%) reported a suicide attempt.^[22]

Delirium and dementia

Delirium and dementia involve the loss of memory, disorientation, hallucinations, delusions, and poor judgment. These conditions often lead to self-destructive behavior. An example might be an accountant who slowly starts to have difficulty remembering numbers and solving addition problems. Although others might view these problems as minimal, he may feel that he is losing his mind and career, leading him to take his own life.

Bulimia

Bulimia has been accompanied by suicidal activity. Predisposing factors include feelings of loneliness, stimulant use, family history of psychiatric disorders, childhood abuse, and difficulty dealing with the public.^[23]

Sex

There is a distinct difference in suicide rates by sex. Men have a significantly higher rate of completed suicides than do women. There are nearly 4 times the number of completed suicides among men than among women. However, women have a much higher rate of suicide attempts.^[1] Often, women select methods, such as an overdose of medication, that allow more time for intervention. Men frequently use methods such as firearms, which are much more lethal.

Females more often use poison when attempting suicide. A study by Hoon et al investigated the risk factors associated with the repetition of deliberate self-poisoning. The associated factors for repeat suicide attempt were sex (female), living without a family, using antidepressants, and a history of psychiatric treatment. Early psychological intervention and close observation is required for patients meeting these criteria. (See the chart below.)^[24]

Genetics

Some authorities believe that genetic factors alone may be involved in suicide, that suicide runs in families, and that having a relative who commits suicide is indeed a risk factor. Therefore, a family history of suicide is very significant. Careful assessments of family history of mental illness and suicide should be a routine aspect of patient evaluation.

Studies continue to show the gene connection in suicidal behavior. Genes related to serotonin have been implicated in histories of second suicide attempts.^[25] Many of the discussed mental illnesses (eg, bipolar disorder) are not only risk factors for suicide but also have strong genetic components.

Family history

A family history of suicidal behavior represents a significant risk factor for the same behavior in offspring. In some families, suicide constitutes a dynamic to deal with crises. Geulayov et al reviewed the literature on these associations and found such a relationship. They also determined that the association is stronger with maternal suicidal behavior versus paternal suicidal behavior and that the risk is increased more in children than in adolescents or adults.^[26]

Availability of firearms

The leading method of suicide remains firearms (see the chart below).^{[27, 2]} When a person with a depressed mood consumes alcohol and has a handgun available, the situation can easily turn lethal.

Of 34,598 completed suicides, 17,352 used guns.^[2] Therefore, a psychiatrist must inquire not only into the patient's suicidal ideation and plans but also into the presence of firearms. Clinicians also must know their state statutes concerning persons with mental illness possessing firearms.^[28] Of interest, the limiting of the purchasing of firearms by local and state background checks has decreased the rate of suicide by guns.^[29]

Data from the National Institute of Mental Health on the differences between men and women and the method of suicide are as follows^[1] :

• Suicide by firearms - Males (56%), females (30%)
• Suicide by suffocation - Males (24%), females (21%)
• Suicide by poisoning - Males (13%), females (40%)

Physical illness

Suicide is often encountered in patients who have a severe medical problem. The risk for suicide increases in the face of a protracted, painful, progressively debilitating disease.

For example, patients undergoing dialysis for end-stage renal disease have a higher rate of suicide than that of the general population.^[30] Other diseases conferring a higher suicide risk include chronic obstructive pulmonary disease (COPD), cancer, human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS), quadriplegia, multiple sclerosis, severe whole-body burns, and chronic heart failure.

A study by Webb et al found a significant link between physical illnesses and suicidal behavior in primary care patients. Coronary heart disease, stroke, chronic obstructive pulmonary disease, and osteoporosis were linked with increased suicide risk among all patients. Elevated risk of suicide was due to clinical depression in all patients, excluding those with osteoporosis.

However, 2 groups of women in the study—those younger than 50 years who were physically ill and older women with multiple physical diseases—were found to have an elevated suicide risk even after depression had been adjusted for.^[31]

Asthma has also been linked to suicide, particularly in young people.^{[32, 33]} The combination of cancer and age is particularly lethal.^[34] Persons experiencing increasing intractable pain are at particularly high risk for suicide. [STOPPED]

Life experiences

Certain recent life events can precipitate suicidal behavior. These include romance-related losses, such as the termination of a love relationship or a divorce; a job termination, or the loss of a pet. The acute loss can be devastating.^[35]

A number of past life events are also linked to suicide. The most important is suicide by a family member or a friend. Not infrequently, history of a father, mother, or sibling committing suicide correlates with suicide by another member of that family.

Suicide by a friend may provoke others to duplicate the event; indeed, suicide has a contagious aspect, especially among adolescents.^[36] Not uncommonly, one suicide in a high school is followed by other suicides or attempts.

As discussed earlier, persons with PTSD are particularly vulnerable to suicide. These individuals may have a history of physical, emotional, or sexual abuse. Damage to the person leads to self-destructive actions.

One study found that sexual violence and having witnessed violence were significant predictors of lifetime suicide attempts. The study, which examined the possible link between trauma exposure and suicidal behavior, was conducted with 4351 adult South Africans from 2002-2004 as part of the World Health Organization (WHO) World Mental Health Surveys. Future research is needed to better understand how and why these experiences in particular increase the risk of suicidal outcomes.^[37]

Victimization by bullying is another experience that has emerged as a correlate to suicidal behavior, and attention must be paid to this in the suicide assessment. In a landmark study by Klomek et al of 5302 children in Finland born in 1981, the authors found evidence that bullying at age 8 years was linked to self-destructive behavior later in life.^[38] When controlling for depression and conduct symptoms, suicide attempts and completions in later life in females were significantly correlated to bullying. However, the same correlation was not apparent for males.^[38]

Economic instability and status

Times of economic change, especially economic depressions, have also been associated with suicides. The start of the Great Depression in the United States was accompanied by a number of suicides. Emile Durkheim noted that in times of major societal alternations, when the rules are in flux and people do not know what is expected of them, the self-destructive rate increases. He termed this period of cultural changes anomie.

Poverty and low income, with concomitantly fewer options and opportunities, also correlate with suicide.^[9]

Media and the Internet

Media can be a suicidal factor in negative and positive ways. The Internet, and other media, can provide information concerning "how-to" methods. A 2008 study found many Websites providing specific techniques on suicide.^[39] That same study also found many antisuicide sites and a surprising number of prosuicide sites.

Books can also have a negative impact on suicide. A patient, after reading the book Final Exit, used one of the methods described to complete a suicide. Furthermore, antipsychiatric Internet sites are available that decry mental health explanations and, for example, show ways to be more effective at being anorexic. The Internet has also been used to broadcast suicides and has been a tool for the development of suicide pacts.^[40]

However, a number of Web sites do provide encouragement for treatments, accounts of successful interventions, and key resources.^[41] In addition, individuals have used the Internet to take online questionnaires that can indicate depression and suicide potential; some college students were found to have sought treatment as a result of taking these surveys.^[42]

Psychodynamic formulation

Several individual psychodynamic ways of viewing suicide exist. In one situation, patients deflect anger inward to hurt themselves when they want to strike out at others. An example would be a young person taking a drug overdose to punish his or her parents after being grounded for misbehavior.

Alternately, the psychoanalytic notion exists of incorporation and killing the interject. In this situation, patients have unconsciously incorporated an ambivalently held object (eg, a family member). For example, a man incorporates his father. He then attacks the interject (father) by killing himself.

Impulsivity

In many cases, suicidal behavior results from a person acting impulsively. Burton and colleagues showed that a lack of executive functioning in the form of poor impulse control inhibition represents a suicide risk. Impulsivity can often separate people who just have suicidal ideation from those who actually attempt suicide.^[43]

However, Spokas et al have suggested that impulsive attempts have valid significance and are similar to premeditated attempts with regard to completed suicide risk.^[44] Hence, an assessment of the patient’s impulse control is critical.

Other risk factors

A number of other factors are closely linked to suicide, including marital status, perceived/actual incarceration, lack of exposure to daylight, and even geographic altitude.

Marital status

People who are married are less suicidal than are those who are single, divorced, or widowed. Isolated individuals are at greater risk for suicide than are those involved with others and their community.

Geographic altitude

A study by Kim et al described altitude as a risk factor for suicide.^[45] Their study concluded that when gun ownership, altitude, and population density are considered as predictor variables for suicide rates on a state-by-state basis, altitude is a significant independent risk factor. Thus, the higher the altitude, the higher the risk of suicide.^[45] This association may be related to metabolic stress associated with mild hypoxia in individuals with mood disorders.

Incarceration and hospitalization

If an individual feels or is indeed trapped, especially those who are incarcerated, they are at suicide risk. Prisoners have a high rate of suicide; this is common during the first hours to first week of being placed in confinement.^{[46, 47]} In contrast, during the first week after a patient's discharge from a psychiatric hospital or unit, the risk of suicide is particularly high.^[48] For many, the transition is difficult, challenging, and anxiety provoking.

The risk of suicide should be extended to all persons involved with the criminal justice system. Webb et al determined that major health and social problems frequently coexist in this population, including offending, psychopathology, and suicidal behavior.^[49] Further prevention strategies are needed for this group, including improved mental health service provision for all people in the criminal justice system, even those found not guilty and those not given custodial services. Better coordination is needed in public services to tackle coexisting health and social problems.

Lack of daylight

Lack of daylight correlates with depression and suicide. Regions with long, dark winters, such as Scandinavia and parts of Alaska (eg, Nome), have high suicide rates. Indeed, persons with seasonal affective disorder (SAD) who live in these regions experience depression in the absence of sunlight and, hence, have a higher susceptibility to depression, which may lead to suicide.

Serum cholesterol

A correlation has long been noted between low levels of total serum cholesterol and suicidal activity. Olié and associates found lower cholesterol levels in persons who attempted suicide, suggesting serum cholesterol levels could possibly be used as a biologic marker for potential suicide risk.^[50]

Sleep problems

Sleep difficulty remains an indicator for not only depression and anxiety disorders but also a risk factor for suicide. Bjørngaard and colleagues studied sleeping problems and suicide in 75,000 Norwegian adults for 20 years. They concluded that problems with sleeping, perhaps in combination with or as a consequence of anxiety and depression, should be considered a marker of suicide risk.^[51]

DHA

Although more studies are needed, a report by Lewis et al suggested that low serum docosahexaenoic acid (DHA) levels may be a risk factor for suicide. The authors studied active-duty US military personnel and found that the risk of suicide death was 14% higher per standard deviation of lower DHA percentage. Among men, the risk of suicide death was 62% greater with low serum DHA status.^[52]

Occurrence in the United States

Suicide represents the tenth leading cause of death in the United States and the third leading cause of death for children, adolescents, and young adults. In 2007, 34,598 suicide deaths occurred, with the national average being 11.26 suicides for every 100,000 people.^{[1, 2]}

Several suicide-related demographic factors often occur in the same person. For example, if a male police officer with major depression and a significant problem with alcohol commits suicide using his service revolver (which, unfortunately, happens not infrequently), 5 risk factors are involved: sex, occupation, depression, alcohol, and gun availability.

In the United States, certain states have higher suicide rates than others, as illustrated by the map below. The Western states have the highest suicide rates, with the exception of Vermont. In addition, living in rural areas carries a higher risk of suicide than living in urban areas.^[53]

The top 15 causes of death (in persons aged 1-85+ y) in the United States in 2007, according to the National Institute of Mental Health, are as follows^[54] :

• Heart disease - 615,616
• Malignant neoplasms - 562,795
• Cerebrovascular - 135,814
• Chronic lower respiratory disease - 127,875
• Unintentional injury - 122,387
• Alzheimer disease - 74,629
• Diabetes mellitus - 71,373
• Influenza and pneumonia - 52,492
• Nephritis - 46,304
• Suicide - 34,592
• Septicemia - 34,543
• Liver disease - 29,185
• Hypertension - 23,963
• Parkinson disease - 20,056
• Homicide - 17,984

International occurrence

Globally, a remarkable range in suicide rates exists. The highest rates for men are in Hungary and Finland. The United States is in the middle, and the lowest rates are in Greece, followed by Mexico and the Netherlands. Moreover, in certain cultures, suicide has been considered more acceptable than in others. For example, the Japanese culture often regarded suicide as an honorable solution to certain situations.

Remarkably, although suicide remains a major cause of death internationally, treatment of suicidal people around the world is quite lacking. Bruffaerts and colleagues used World Health Organization (WHO) data to conclude that most people with suicidal ideation and plans and who have made suicide attempts do not receive treatment. This finding extended across various different areas around the world, especially in low-income countries.^[55]

Religion-related demographics

Religion may also play a role in suicide. Historically in the United States, Protestants have had a higher rate of suicide than either Catholics or Jews. Some religions may encourage suicide in situations of disgrace or for patriotic reasons.

Race-related demographics

In the United States, most suicides occur within the white population. The rate for white men in 2007 was 13.5 cases per 100,000 population; for black men, 5.1 cases per 100,000 population; and for Hispanic men, 6.0 cases per 100,000 population.^[1] However, the rate for Native American and Alaska Native men was 14.3 cases per 100,000 population.^[1]

Furthermore, in sampling surveys (one from 53 countries and one from 43 countries), Voracek et al found that regardless of sex or age, people with a lighter skin color have a higher rate of suicide than do those with darker skin color.^[56]

Sex-related demographics

The relationship between sex and suicide represents one of the most salient and enduring features in suicide-related statistics. Men commit suicide far more frequently than women. In the United States, the difference is quite striking. Suicide was the 7th leading cause of death for males and the 15th leading cause of death for females, in 2007.^[1]

However, women make 2-3 times more suicide attempts than men do.^[57] Furthermore, the sex differential continues in those who are suicidal who seek help; females are much more prone to go for medical and psychiatric aid then men are.^[58]

Although the facts can be interpreted in many ways, including as they relate to method (men use firearms, and women use poison) and the ability to handle feelings, the fact remains that difference in frequency related to sex is a powerful and relatively consistent finding across a wide range of other demographic categories, such as age, socioeconomic factors, and region.

Age-related demographics

In general, the suicide rate increases with age, with a major spike in adolescents and young adults. In recent decades, the number of adolescent suicides has increased dramatically. The 2007 Youth Risk Behavior Surveillance showed that 6.9% of high school students had attempted suicide in the year before the survey.^[59]

With increasing age, a critical relationship emerges with suicide. Geriatric suicide is extremely prevalent. People older than 75 years have the highest rate of suicide. In 2007, the incidence of suicide in persons aged 75 years and older was 36.1 for every 100,000 people, compared with the national average of 11.26 suicides for every 100,000 people.^[1] Suicide risk in various cities in England has been found to be 67 times higher for older adults (≥ 60 years) presenting with self-harm than for older adults in the general population. The highest suicide rates were found among men aged 75 years and older.^[60] The older age group also maintains an alarming connection with murder-suicides. (Note the chart below for suicide figures based on sex, race, and age.)^[61]

Occupation-related demographics

Police and public safety officers are at increased risk for suicide. The long hours of work, the scenes they witness daily, the availability of guns, and the silence encouraged by the profession (keeping within the "wall-of-blue"), as well as alcohol usage and divorce, contribute to this risk.

Physicians, especially those who deal with progressively terminally ill patients, as well as dentists, also have a high rate of suicide. In the United States, the medical field loses the equivalent of a medical school class each year by suicide. Perhaps, elements of obsessive and perfectionist tendencies combined with personal feelings of isolation may contribute to this high number of self-induced deaths.

Suicide risk in military personnel has been increasing, as demonstrated in the chart below.

Seasonal variances in suicide

Most suicides occur in the spring; the month of May particularly has been noted for its high rate of suicide. The speculation is that during the winter and early spring, people with depression are often surrounded by persons who are feeling downhearted because of the weather. However, with the arrival of the spring season and the month of May, people who are depressed because of the weather are cheered and people who are depressed for other reasons remain depressed. As others cheer up, those who remain miserable must confront their own unhappiness.

It is critical for patients to appreciate that suicidal behavior reflects mental illness. Moreover, the patient's family needs to see the patient’s behavior as a sign of an underlying problem. Family members often struggle with a series of conflicting feelings about the patient’s suicidal activities. Education and an opportunity to discuss their feelings can help.

Helpful Web sites for patients include the following:

• American Association of Suicidology
• NIMH - Suicide Prevention
• NIMH – Warning Signs of Suicide
• US Centers for Disease Control and Prevention (CDC) Suicide Prevention

For patient education information, see the Depression Center, as well as Depression and Suicidal Thoughts.

A clear and complete evaluation and clinical interview provide the information upon which to base a suicide intervention. Although risk factors offer major indications of the suicide danger, nothing can substitute for a focused patient inquiry. However, although all the answers a patient gives may be inclusive, a therapist often develops a visceral sense that his or her patient is actually going to commit suicide. The clinician's reaction counts and should be considered in the intervention.

Suicidal ideation

Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is highly linked to completed suicide. Some inexperienced clinicians have difficulty asking this question. They fear the inquiry may be too intrusive or that they may provide the person with an idea of suicide. In reality, patients appreciate the question as evidence of the clinician's concern. A positive response requires further inquiry.

Suicide plans

If suicidal ideation is present, the next question must be about any plans for suicidal acts. The general formula is that more specific plans indicate greater danger. Although vague threats, such as a threat to commit suicide sometime in the future, are reason for concern, responses indicating that the person has purchased a gun, has ammunition, has made out a will, and plans to use the gun are more dangerous. The plan demands further questions. If the person envisions a gun-related death, determine whether he or she has the weapon or access to it.

Purpose of suicide

Determine what the patient believes his or her suicide would achieve. This suggests how seriously the person has been considering suicide and the reason for death. For example, some believe that their suicide would provide a way for family or friends to realize their emotional distress. Others see their death as relief from their own psychic pain. Still others believe that their death would provide a heavenly reunion with a departed loved one. In any scenario, the clinician has another gauge of the seriousness of the planning.

Potential for homicide

Any question of suicide also must be coupled with an inquiry into the person's potential for homicide. Suicide is often thought to represent aggression turned inward, whereas homicide represents aggression turned outward. Because suicide constitutes an aggressive act, the question regarding homicidal tendencies must be asked.

Additional questions

Collateral questions should be asked based on the reviewed risk factors. These questions deal with any family members or friends who have killed themselves and include questions about symptoms of depression, psychosis, delirium and dementia, losses (especially recent ones), and substance abuse.

Signs and risk factors

The following is a list of 12 things that should alert a clinician to a real suicide potential:

• Patients with definite plans to kill themselves - People who think or talk about suicide are at risk; however, a patient who has a plan (eg, to get a gun and buy bullets) has made a clear statement regarding risk of suicide
• Patients who have pursued a systematic pattern of behavior in which they engage in activities that indicate they are leaving life - This includes saying goodbye to friends, making a will, writing a suicide note, and developing a funeral plan
• Patients with a strong family history of suicide - Family history of suicide is especially indicative of suicide risk if the patient is approaching the anniversary of such a death or the age at which a relative committed suicide.
• The presence of a gun, especially a handgun
• Being under the influence of alcohol or other mind-altering drugs - Drug abuse is especially significant if the drugs are depressants.
• If the patient encounters a severe, immediate, unexpected loss - Eg, when a person is fired suddenly or left by a spouse
• If the patient is isolated and alone
• If the person has a depression of any type
• If the patient experiences command hallucination - A command hallucination ordering suicide can be a powerful message of action leading to death.
• Discharge from psychiatric hospitals - Patients are at suicide risk upon discharge from a psychiatric hospital, which is a very difficult time of transition and stress; the structure, support, and safety of the institution are no longer available to the patient; the patient feels apprehension and is confronted with the reality of change, which translates into fright and vulnerability.
• Anxiety - Anxiety in all of its forms leads to a risk for suicide; the constant sense of dread and tension proves unbearable for some
• Clinician's feelings - As mentioned earlier, regardless of what the patient says or does, it matters if the clinician has a feeling that patient is going to commit suicide; such perceptions are part of clinical judgment and are an important part of the suicide assessment and intervention.

Other sources of information

Utilize all of the information available when assessing suicide risk. In addition to the material obtained through the clinical interview, use information from other sources, including family interviews or interviews with friends or coworkers. First responders or other medical personnel may also have key information. In addition, a suicide note may have been written.

A number of written and online tests will indicate the presence of a significant depression and significant thoughts and plans for self-destruction. These include the following self-administered tests:

• Beck Depression Inventory
• Hamilton Depression Rating Scale
• HANDS (Harvard Department of Psychiatry/National Depression Screening Day Scale) Depression Screening Questionnaire^[62]
• Minnesota Multiphasic Personality Inventory (MMPI)

Using the Collaborative Longitudinal Study of Personality Disorders (CLPS), Yen et al found that the predictive power of the self-harm subscale of the Schedule for Nonadaptive and Adaptive Personality (SNAP) may be a helpful screening tool for risk of suicide attempts in nonpsychotic psychiatric patients.^[63]

Ballard et al, in a study to determine how children react to suicide screening in an emergency department (ED), suggested that pediatric patients supported suicide screening in the ED. Further studies are needed to evaluate the impact of such screening on referral practices and to link screening efforts with interventions.^[64]

A host of thoughts and behaviors are associated with self-destructive acts. Although many assume that people who talk about suicide will not follow through with it, the opposite is true; a threat of suicide can lead to the completed act, and suicidal ideation is highly correlated with suicidal behaviors.

Numerous activities are associated with committing suicide, including the following:

• Making a will
• Getting the house and affairs together
• Unexpectedly visiting friends and family members
• Purchasing a gun, hose, or rope
• Writing a suicide note
• Visiting a primary care physician

With regard to the last item, a significant number of people see their primary care physician within 3 weeks before they commit suicide. They come for a variety of medical problems, but rarely will they state they are contemplating suicide. Therefore, the practitioner must pay attention to the entire person; the physician must look for factors in the patient's life beyond the chief complaint.

Suicide-related characteristics

Individuals who are suicidal have a number of characteristics, including the following:

• A preoccupation with death
• A sense of isolation and withdrawal
• Few friends or family members
• An emotional distance from others
• Distraction and lack of humor - They often seem to be "in their own world" and lack a sense of humor (anhedonia)
• Focus on the past - They dwell in past losses and defeats and anticipate no future; they voice the notion that others and the world would be better off without them.
• Haunted and dominated by hopelessness and helplessness - They are without hope and therefore cannot foresee things ever improving; they also view themselves as helpless in 2 ways: (1) they cannot help themselves, and all their efforts to liberate themselves from the sea of depression in which they are drowning are to no avail; and (2) no one else can help them

The mental status review is designed to focus on evaluating an individual's potential for committing suicide.

Appearance

In addition to noting the dress and hygiene of patients who are depressed (eg, disheveled, unkempt and unclean clothing), the clinician should assess these individuals for other signs of suicide risk. First, look for physical evidence of suicidal behavior. This includes wrist lacerations and neck rope burns. Be aware that more than 1 sign can indicate suicidal behavior. In one example, a woman who was brought to an emergency department because she had cut her left wrist was found, on physical examination, to have 5 vertical lacerations on her abdomen.

Affect

Depression and anxiety are commonly seen in people who are suicidal. One specific emotion of concern is the patient exhibiting a flat affect when describing his or her thoughts and plans of suicide and self-destructive behavior.

Thoughts

Three types of thought changes represent areas for major focus and concern. The first consists of command hallucinations telling the patient to kill himself or herself. These are usually auditory in nature and often take the form of the deity's voice (eg, "I hear God commanding me to kill myself, because I am bad").

The second type consists of delusions. These include, "The world and my family would be better off with me dead" or "If I take my life, I will be reunited in heaven with my mother."

The third type of thought involves the obsession of a patient wanting to take his or her own life. Some patients focus their lives on their suicide. (See the chart below.)

Suicide and homicide

Inquiring into suicide potential is an absolute requirement. The more specific the ideas and plans for suicide, the greater the possibility of suicide. Those with plans to purchase a gun exhibit a clear danger.

In addition to suicide inquiry, the clinician must ask about homicidal potential. Aggression turned inward is suicide; aggression turned outward is homicide. Homicide needs to be inquired about for the following reasons:

• It is part of a complete mental status examination
• There is linkage between the homicide and suicide - For example, in adolescents, 2 of the 4 leading causes of violent death are homicide and suicide^[59]
• Although infrequent, homicide/murder and suicide are a reality^[61]

Judgment, insight, and intellect

An assessment of the patient’s judgment is important. How a person has handled stress and how he or she will handle it in the future are major concerns. Keep in mind that the less judgment the patient has, the greater the potential for suicide.

It is important to note, for example, how the individual perceives attempts at suicide. The person who sees an overdose as a cry for help has better insight than the person who awakes from an overdose and says, "I wish I were dead."

The key idea with intellect assessment is to determine whether the person understands the sequences of his or her behavior. For example, did the person know that walking into traffic would be dangerous?

Orientation and memory

The focus of this part of the mental status review is to determine if the person is delirious or has dementia. In either case, the patient, as a result of disorientation and loss of recollection, can perform many self-destructive behaviors.

The treatment of a suicidal patient involves a 2-phase process. First and foremost, the patient’s safety must be assured; this is the intervention. Intervention is based on the application of risk factors coupled with a clinical inquiry. The second step is treatment aimed at diagnosing and treating the underlying mental disorder.

In many cases, swift, decisive intervention can prevent a person from committing suicide. Because of this preventable aspect of suicide, recognizing and taking action if the potential arises is critical. Based on the clinical assessment and all of the information available, if the person is indeed suicidal, the intervention should consist of multiple steps.

The individual must not be left alone. In the ED, such a recommendation is handled easily by hospital security personnel. In other settings, summon assistance quickly. In an isolated place, call 911. Involve family or friends; they can remain with the patient while treatment arrangements are made.

Remove anything that the patient may use to hurt or kill him or herself. Remove sharp or potentially dangerous objects. Ask the patient for any weapon, such as knives or pills, and secure them away from the patient.

The suicidal patient should be treated initially in a secure, safe, and highly supervised place. Inpatient care at a hospital offers one of the best settings. Most managed care companies recognize the medical necessity of hospitalization in situations in which the suicide danger is acute.

A study of the association between the provision of mental health services and suicide rates found that removing ligature points (places where things like ropes could be attached to) was associated with significant reductions in the overall psychiatric inpatient suicide rate and in the rate of inpatient suicide by hanging.^[65]

Postintervention treatment

Suicide constitutes an immediate solution to an underlying problem. The critical factor is first to keep the patient alive and to treat the underlying condition. Once the person is safe, start a series of outpatient treatments in less restrictive settings. Implementation of key mental health service recommendations, such as 7-day follow-up after discharge and 24-hr crisis team support, is associated with significant reductions in suicide.^[65]

Medication use is based on the patient’s underlying mental disorder. Each mental disorder requires specific medications. For example, a patient with a major depression feels hopelessness and helplessness. These perceptions lead the individual to suicidal ideation and plans. Once that person’s safety has been assessed and assured, the use of an antidepressant is indicted to lift and reverse the despair.

Alternatively, a patient with schizophrenia experiences self-destructive command hallucinations telling that person to commit suicide. Once the patient’s safety has been established, an antipsychotic medication is indicated.

The key to diagnosis is taking the patient’s psychiatric history and conducting a thorough mental status examination.

This section details steps a clinician should take in cases of completed suicide. Practitioners must work with the patient's family and friends, as well as with the other patients who knew the deceased.^[66]

Upon learning of the death of a patient, focus on the immediate situation. Reschedule other patients and, whenever possible, meet with the family. Family members appreciate the clinician's interest and the opportunity to voice their feelings and reactions. In some situations, the family may have expected the outcome. In others, they may be hurt and angry. The clinician's job is to be responsible and responsive to them. This intervention may require more than 1 session. Be available to family members, listen to them, and share their loss.

Often, other patients knew the deceased person. Without violating confidentiality, provide extra attention to these patients. This could include sessions to allow them to express their reactions to the death and loss. If the patient who committed suicide was an inpatient, convening a group meeting and discussing the other patients' reactions is important. The staff should also have an opportunity to discuss their feelings.

Finally, the practitioner must take time to review and discuss the event. Often, seeking a senior clinician is effective. The therapist needs an opportunity to recover and heal. Later, a psychological autopsy can be performed, but in the acute phase, the clinician requires sympathy and support.