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Suicide

Suicide is one of the leading causes of death worldwide. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, and hospitalization Hospitalization The confinement of a patient in a hospital. Delirium to ensure patient safety Patient Safety Efforts to reduce risk, to address and reduce incidents and accidents that may negatively impact healthcare consumers. Patient Safety: Types of Medical Errors.

Last updated: Oct 12, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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 Family History Adult Health Maintenance
  • Ethnic groups:
    • American Indian/Alaska Native population
    • Non-Hispanic whites
  • Special groups:
    • Military personnel
    • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship living in rural areas
    • Healthcare workers
    • First responders
    • Mining/construction workers
    • Lesbian, gay, or bisexual young people
  • Modifiable risk factors:
    • Mental illness (improved prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas 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 Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • 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

Related videos

Management

Suicide risk assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care

Suicide risk assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care is the process of making close observations, evaluations, and estimations of an individual’s probability Probability Probability is a mathematical tool used to study randomness and provide predictions about the likelihood of something happening. There are several basic rules of probability that can be used to help determine the probability of multiple events happening together, separately, or sequentially. Basics of 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 Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 Patient Safety Efforts to reduce risk, to address and reduce incidents and accidents that may negatively impact healthcare consumers. Patient Safety: Types of Medical Errors:
    • Sitter
    • Prevent access to firearms/harmful objects
  • Proper documentation Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature. It often involves authenticating or validating information. Advance Directives of the patient case
  • Agitated patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship:
    • Consider medications (e.g., benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines or antipsychotics). 
    • Restraints for severely agitated patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship not improving on medications
  • Urgent interventions:
    • Break confidentiality Confidentiality Confidentiality is a set of rules that dictates the protection of health information shared by a patient with a physician. In general, this information should only be used to dictate medical decision-making steps and can only be disclosed to a 3rd party with the patient’s express consent. Patient-Doctor Confidentiality: Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship are obligated to warn family members and appropriate authorities to ensure patient safety Patient Safety Efforts to reduce risk, to address and reduce incidents and accidents that may negatively impact healthcare consumers. Patient Safety: Types of Medical Errors.
    • Hospitalization Hospitalization The confinement of a patient in a hospital. Delirium: 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 Hospitalization The confinement of a patient in a hospital. Delirium.
    • 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 Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder (MDD): 
    • Antidepressants, such as selective serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS reuptake inhibitors ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants), need weeks to show improvement. 
    • Note: SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants carry a black box warning for the potential increase of suicidal ideation among the pediatric and adolescent populations.
    • Avoid older antidepressant Antidepressant Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressants groups such as tricyclic antidepressants Tricyclic antidepressants Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. Tricyclic Antidepressants and monoamine oxidase inhibitors Monoamine oxidase inhibitors Monoamine oxidase inhibitors are a class of antidepressants that inhibit the activity of monoamine oxidase (MAO), thereby increasing the amount of monoamine neurotransmitters (particularly serotonin, norepinephrine, and dopamine). The increase of these neurotransmitters can help in alleviating the symptoms of depression. Monoamine Oxidase Inhibitors ( MAOIs MAOIs Monoamine oxidase inhibitors are a class of antidepressants that inhibit the activity of monoamine oxidase (MAO), thereby increasing the amount of monoamine neurotransmitters (particularly serotonin, norepinephrine, and dopamine). The increase of these neurotransmitters can help in alleviating the symptoms of depression. Monoamine Oxidase Inhibitors) given the potential for lethal overdose.
    • Electroconvulsive therapy Electroconvulsive therapy Electrically induced convulsions primarily used in the treatment of severe affective disorders and schizophrenia. Major Depressive Disorder:
      • Severe MDD not responding to medications
      • MDD with psychotic features
      • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who refuse to eat or drink 
  • Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia: clozapine Clozapine A tricyclic dibenzodiazepine, classified as an atypical antipsychotic agent. It binds several types of central nervous system receptors, and displays a unique pharmacological profile. Clozapine is a serotonin antagonist, with strong binding to 5-HT 2a/2c receptor subtype. It also displays strong affinity to several dopaminergic receptors, but shows only weak antagonism at the dopamine D2 receptor, a receptor commonly thought to modulate neuroleptic activity. Agranulocytosis is a major adverse effect associated with administration of this agent. Second-Generation Antipsychotics for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia and suicidal thoughts 
  • Bipolar Bipolar Nervous System: Histology patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship: Lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly maintenance therapy decreases the incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of suicide. 
  • Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. 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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