Suicide

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Basics

Description

Suicide and attempted suicide are significant causes of morbidity and mortality.

Epidemiology

  • Predominant sex
    • Women attempt suicide 1.5 times more often than men. Men complete suicide 3 times more often than women. Men are more likely to choose a means with high lethality, such as firearms.
  • Predominant age: adolescent (2nd leading cause of death), 10th leading cause of death overall, per 2016, CDC statistics (latest available)
  • Marital status: single > divorced; widowed > married
  • Worldwide, suicide is the 18th leading cause of death per World Health Organization reports from 2018 but the 2nd leading cause of death among youths (ages 15 to 29 year olds).

Incidence
In 2016, 10th leading cause of death in adults in the United States. Military service (not specifically active duty) is associated with increased risk. A 2017 Veterans Administration study reported that veterans had a 22% increased rate of suicide over civilians.

Risk Factors

  • “Human understanding is the most effective weapon against suicide. The greatest need is to deepen the awareness and sensitivity of people to their fellow man” (Shneidman, American Association of Suicidology [AAS]).
  • Be alert to a combination of “perturbation” (increased emotional disturbance) and “lethality” (having the potential tools to cause death).
  • 80% who complete suicides had a previous attempt.
  • 90% who complete suicide meet Diagnostic and Statistical Manual criteria for Axis I or II disorders: major depression, bipolar disorder, anorexia nervosa, panic disorder, borderline and antisocial personality disorders. Schizophrenia or acute onset of psychosis is also risk factor due to command hallucinations or even the negative affect or hopelessness that can accompany these states.
  • Substance use and withdrawal (alcohol, hallucinogens, opioids)
  • Family history of suicide
  • Physical illness, including head injury (TBI associated with 20% increased risk of death by suicide) (1)
  • Despair: emotional pain and without hope and, consciously or unconsciously, unworthy of help
  • Among teenagers: not feeling “connected” to their peers or family; being bullied; gender identity issues; poor grades
  • Among veterans: childhood history of abuse; a diagnosis of major depressive disorder and multiple inpatient psychiatric admissions were found to be the “best predictors of enhanced suicide risk” (2).
  • Psychosocial: recent loss. What may seem to be a small loss (to a medical provider) may be a devastating loss to the patient. Patient-specific factors need to be taken into account: social isolation, anniversaries, and holidays. Patients who attempt suicide also seem to have impaired decision-making skills and risk awareness and increased impulsivity compared with patients who have never attempted suicide (3).
  • If a patient is incompetent (e.g., too delusional) to alert providers about the potential for suicide, the patient at increased risk for self-harm and providers should consider hospitalization.
  • Access to lethal means: firearms, poisons (including prescription and nonprescription drugs; pesticides) (common method of self-harm in developing countries)

General Prevention

  • Know how to access resources 24/7 within and outside of the health care institution.
  • Screen for risk: Use screening instruments BUT keep in mind risks particular to each patient, which could lead to increased risks not captured in some screening tools. Screening instruments include the Patient Health Questionnaire-2 (PHQ-2), the PHQ-9, the Columbia Suicide Severity Rating Scale, Beck Scale for Suicide Ideation, Linehan Reasons for Living Inventory, and Risk Estimator for Suicide.
  • Treat underlying mental and medical illnesses and substance abuse.
  • Screen for possession of means of harm, including prescribed/unprescribed drugs, poisons, and firearms (encourage the removal of guns from the home and the relinquishment of gun licenses).
  • Create a safety plan for patients at risk for suicide and their families, including education about how to access emergency care 24 hours a day.
  • Public education about how to help others access emergency psychiatric care. Suicidal people may initially confide in those they trust outside health care (e.g., family members, religious leaders, “healers,” or to retail service providers, such as hairdressers and bartenders).
  • Law enforcement education through the FBI’s National Center for Analysis of Violent Crime in recognizing and triaging potential “suicide by cop” events (deliberate attempt to trigger lethal force); thought to be responsible for approximately 20% of fatal police shootings in the United States between 1998 and 2006 (1)
  • For the military: multiple resources: http://www.realwarriors.net. Suggested treatments include cognitive restructuring techniques (that their experience with adversity can be a source of strength) and help with problem solving (so the service member does not feel like a “burden”), therapeutic martial arts training, focus on Vets’ helping others: “Power of 1” initiative (any “one” helpful contact could save a life).
  • For teens, young adults, and their educators: suggestions and advice for students/families and educators: http://www.cdc.gov/healthyyouth/adolescent-health; http://www.stopbullying.gov
  • In developing world countries, pesticide ingestion is a common method of suicide. Limiting free access has led to reduced suicide rates.

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