Suicide

Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Management of a suicidal patient includes medication, psychotherapy, and hospitalization to ensure patient safety.

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Epidemiology

General data

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.

Risk factors

  • 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)

Protective factors

  • 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
  • Pregnancy
  • 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

Nomenclature

  • 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

  • Firearms: 
    • Most common method of completed suicide
    • More commonly used by men
  • Poisoning: 
    • Prescription medications are used more than illicit substances.
    • More commonly used by women 
  • Hanging/suffocation
  • Self-inflicted trauma

Management

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

General approach

  • Reduce immediate risk/maintain patient safety:
    • Sitter
    • 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
  • Discharge: 
    • 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. 
  • Psychotherapy:
    • CBT or problem solving therapy
    • Indicated before and after a suicide attempt to prevent subsequent attempts

References

  1. Matthew Sochat, Tao Le, and Vikas Bhushan. (2019). First Aid for the USMLE Step 1, (29th ed.), page 550.
  2. 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.
  3. Bauer, I. (2021). Depressive disorders: Update on diagnosis, etiology, and treatment. DeckerMed Medicine.
  4. 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 
  5. 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 
  6. O’Rourke, M., Jamil, R., Siddiqui, W. Suicide screening and prevention. [Updated 2020 Nov 30]. In: StatPearls [Internet]. Treasure Island (FL). https://www.ncbi.nlm.nih.gov/books/NBK531453/
  7. 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 
  8. The National Institute of Mental Health Information Resource Center. Suicide. Retrieved May 14, 2021, from https://www.nimh.nih.gov/health/statistics/suicide

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