Description

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

Epidemiology

• Women attempt suicide 1.5 times more often than men. Men complete suicide 3 times more often than women.
• In the United States; predominant age: 10 to 14 years; age 25 to 34 years (2nd leading cause of death), 11th leading cause of death overall, per 2021 Centers for Disease Control and Prevention (CDC) (latest available data as of September 2023).
• In the United States, more people died because of suicide in 2022 (>49,000) per CDC’s initial review of 2022 data (the most recent available). CDC’s analysis of finalized data from 2021 showed a sharp rate increase among specific populations: American Indian/Alaska Native: 42.6 per 100,000, 17% increase from 2020 to 2021; and during that same timeframe, rates increased for young adults aged 10 to 24 years. The CDC, through its Youth Risk Behavior Survey and researchers connected with the Trevor Project, which advocates for gender nonconforming youths, noted trends of increasing suicidal thoughts and behaviors (attempts) had increased—and that young adults who are gender nonconforming were 2 to 3 more times likely to have had a suicide attempt over the past year than young adults who are male and identify as gender conforming.
• Worldwide, suicide is the 4th leading cause of death among youths (ages 15 to 29 years), 15th leading cause of death per World Health Organization reports from 2020.

Risk Factors

• 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, 5th edition criteria for major depression, bipolar, anorexia, panic, and personality disorders. Schizophrenia or acute onset of psychosis are also risk factors due to command hallucinations and hopelessness that can accompany these states. Delusional disorders—specifically persecutory and somatic delusions—are associated with increased depression accompanying those symptoms (1).
• Substance use and withdrawal
• Family history of suicide
• Physical illness, including head injury (associated with 20% increased risk of death by suicide)
• 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 (2).
• 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 risks particular to each patient, and might not be captured in some screening tools (see “Risk Factors”); and providers own biases in assessing risk. 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 Motto Risk Estimator for Suicide.
• Treat underlying mental and medical illnesses and substance abuse. Continuity of care has been identified as a key protective factor. It is among the strategies in the “Perfect Depression Care” initiative out of a Detroit area HMO, and was associated with a 77% decrease in suicide rate.
• Screen for possession of means of harm, including prescribed/unprescribed drugs, poisons, and firearms
• Create a safety plan for patients at risk patients 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.
• For emergencies and imminent risk of harm, call 911.
• For additional resources, for needs ranging from quick support to educational:
  • For the military: Military Health System: Real Warriors Campaign: https://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 anyone in need within the United States: https://988lifeline.org/; text: Enter 988 to get a prompt allowing for communication via phone/text message/chat.
  • For teens, their families and their educators: CDC: https://www.cdc.gov/healthyyouth; StopBullying.gov: http://www.stopbullying.gov; https://988lifeline.org/help-yourself/youth/; text: https://988lifeline.org/chat/
  • For members of “minority” populations (ethnic or gender) who are concerned that their cultures/life experiences might not be understood by the medical establishment, resources with counselors with specific knowledge/training include the following: https://988lifeline.org/help-yourself/black-mental-health/; https://988lifeline.org/help-yourself/native-americans/.
  • For health care providers: multiple links available via links above; additional resources at the national Suicide Prevention Resource Center: https://sprc.org/