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.
• In the United States: predominant age: adolescence through age 34 (2nd leading cause of death), 11th leading cause of death overall, per 2019 Centers for Disease Control and Prevention (CDC) (latest available)
• Worldwide, suicide is the 4th leading cause of death among youths (age 15 to 29), 17th leading cause of death per World Health Organization (WHO) reports from 2019.

Incidence
The COVID-19 pandemic—with its lockdowns, school closures, excess deaths (3rd leading cause in the United States) in 2020—led to concerns for a possible “tidal wave” of suicides. While initial data from WHO and CDC for 2020 showed an overall decrease in completed suicides, several early U.S. studies showed 27% to a doubling of suicides in non-whites during this period (1).

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 increased emotional disturbance and access to the potential tools to cause death).
• 80% who complete suicide had a previous attempt.
• 90% who complete suicide meet Diagnostic and Statistical Manual criteria for major depression, bipolar disorder, anorexia, panic, personality disorders. Schizophrenia or acute onset of psychosis are also risk factors due to command hallucinations and hopelessness that can accompany these states.
• Substance use and withdrawal
• Family history of suicide
• Physical illness, including head injury (associated with 20% increased risk of death by suicide) (2)
• Despair: emotional pain and without hope; feeling unworthy of help
• For teenagers: not feeling “connected” to their peers or family; being bullied; gender identity issues; poor grades
• Among veterans: childhood abuse; major depression; multiple psychiatric hospitalizations are the best predictors of suicide risk (3).
• Psychosocial: recent loss. What may seem to be a small loss may be a devastating for the patient. Patient-specific factors need to be taken into account including anniversaries and holidays. Providers should inquire how COVID-19 has affected them: isolation; deaths of loved ones; job loss; infection (leading to risk of ”long COVID,” with physical and mental health disability). Screen for impaired decision-making skills: lack of risk awareness and increased impulsivity are more common in patients who have attempted suicide (4).
• If a patient is incompetent (e.g., too delusional, too psychotic) to alert providers about the potential for suicide and appears to be at increased risk for self-harm, providers should consider hospitalizing the patient.
• Access to lethal means: firearms, poisons; including prescription and nonprescription drugs; pesticides

General Prevention

• Educate patients about 24/7 resources.
• Screen for risk: Use screening instruments BUT providers need to keep in mind: (i) risks particular to each patient, and might not be captured in some screening tools (see “Risk Factors” above) and (ii) providers own biases in assessing risk (e.g., in wheelchair mobile patients, assuming a lower quality of life and underestimating resilience) (5). 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 and their families, including how to access 24/7 emergency care.
• Public education about how to help others access emergency psychiatric care. Suicidal people may initially confide in those they trust outside health care.
• 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 (2)
• For the military: multiple resources: 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, their families, and their educators: http://www.cdc.gov/healthyyouth; 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.