In the United States:
- 4th leading cause of death in 2011
- 33% suicide increase between 1999–2019
- 1 person dies from suicide every 11 minutes
- More than 47,000 people die by suicide yearly
- Women attempt suicide 3–4 times more often than men.
- Men are 3–4 times more likely to complete suicide.
- Prior attempt (highest risk factor)
- Access to a firearm
- Men > 65 years old
- Positive family history
- Ethnic groups:
- American Indian/Alaska Native population
- Non-Hispanic whites
- Special groups:
- Military personnel
- Patients living in rural areas
- Healthcare workers
- First responders
- Mining/construction workers
- Lesbian, gay, or bisexual young people
- Modifiable risk factors:
- Mental illness (improved prognosis after starting treatment)
- Chronic medical illness
- Substance use disorder
- Life stressors (e.g., unemployment, financial stressors, homelessness, divorce)
- Reflective and deep thinking skills
- Participation in programs for help with mental illness and substance abuse disorder
- Access to psychiatric help
- Support from friends and family
- Cultural programs discouraging suicide
- Religious beliefs (faith in God and religious activities)
- Constructive activities (e.g., sports or artistic pursuits)
Nomenclature and Methods of Suicide
- Suicide: death caused by self-directed, injurious behavior with the intent to die
- Suicide attempt:
- Nonfatal, self-directed, potentially injurious behavior with the intent to die
- May not result in injury
- Suicidal ideation:
- Thinking about or planning suicide
- Thoughts of hurting oneself (can range from a detailed plan to a fleeting consideration)
- Does not necessarily include the final act of suicide
Methods of suicide
- Most common method of completed suicide
- More commonly used by men
- Prescription medications are used more than illicit substances.
- More commonly used by women
- Self-inflicted trauma
Suicide risk assessment
Suicide risk assessment is the process of making close observations, evaluations, and estimations of an individual’s probability to commit suicide. The assessment includes evaluating a patient’s suicidal ideation, plan, and intent.
Examples of alert signs:
- Patient created a clear plan.
- Patient started writing a will, funeral plan, or suicide note.
- Patient says goodbye to friends and family.
- Patient is in severe, acute, immediate stress.
- Recent suicide attempt is kept secret.
- Recent suicide attempt was a highly lethal method (e.g., deep, cutting wounds).
Risk group stratification
Based on the suicide risk assessment, patients are divided into 2 groups:
- High imminent-risk group:
- Patient has a clear plan to commit suicide.
- The patient usually shows signs of alert.
- Urgent intervention is required.
- High non-imminent–risk group:
- Patient has thoughts, but no concrete plans, to commit suicide.
- Generally managed in an outpatient setting
- Reduce immediate risk/maintain patient safety:
- Prevent access to firearms/harmful objects
- Proper documentation of the patient case
- Agitated patients:
- Consider medications (e.g., benzodiazepines or antipsychotics).
- Restraints for severely agitated patients not improving on medications
- Urgent interventions:
- Break confidentiality: Physicians are obligated to warn family members and appropriate authorities to ensure patient safety.
- Hospitalization: may be against the patient’s will and with help of law enforcement
- Suicide risk is increased in the initial days and weeks postdischarge from psychiatric hospitalization.
- Ensure close follow-up with a mental health professional within 72 hours postdischarge.
- Provide resources and patient education (e.g., suicide hotline).
- Discuss the temporary removal of guns with the patient and family.
Management of underlying psychiatric disorders
- Major depressive disorder (MDD):
- Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), need weeks to show improvement.
- Note: SSRIs carry a black box warning for the potential increase of suicidal ideation among the pediatric and adolescent populations.
- Avoid older antidepressant groups such as tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) given the potential for lethal overdose.
- Electroconvulsive therapy:
- Severe MDD not responding to medications
- MDD with psychotic features
- Patients who refuse to eat or drink
- Schizophrenia: clozapine for patients with schizophrenia and suicidal thoughts
- Bipolar patients: Lithium maintenance therapy decreases the incidence of suicide.
- CBT or problem solving therapy
- Indicated before and after a suicide attempt to prevent subsequent attempts
- Matthew Sochat, Tao Le, and Vikas Bhushan. (2019). First Aid for the USMLE Step 1, (29th ed.), page 550.
- Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 8, Mood disorders, pages 347–386. Philadelphia, PA: Lippincott Williams and Wilkins.
- Bauer, I. (2021). Depressive disorders: Update on diagnosis, etiology, and treatment. DeckerMed Medicine.
- Schreiber, J. (2020). Suicidal ideation and behavior in adults. UpToDate. Retrieved March 18, 2021, from https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults
- Kennebeck, S. (2019). Suicidal behavior in children and adolescents: epidemiology and risk factors. UpToDate. Retrieved March 18, 2021, from https://www.uptodate.com/contents/suicidal-behavior-in-children-and-adolescents-epidemiology-and-risk-factors
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- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Suicide prevention. Retrieved May 14, 2021, from https://www.cdc.gov/suicide/index.html
- The National Institute of Mental Health Information Resource Center. Suicide. Retrieved May 14, 2021, from https://www.nimh.nih.gov/health/statistics/suicide