Suicide

Suicide is the act of intentionally ending one's own life. If this action does not have a fatal outcome, it is called a suicide attempt. Thoughts of wanting to die, or a preoccupation with suicide, is referred to as suicidal ideation, which can involve concrete plans and suicidal intent (active suicidal ideation). Suicide is significantly more common in men than women, while the rate of attempted suicide is higher in women. Many factors increase the risk of suicide, most importantly, a history of previous suicide attempts. Suicidal ideation is often associated with psychiatric illness (e.g., major depressive disorder, bipolar disorder). The most important diagnostic step is the evaluation of suicidal ideation and the risk of suicide. Acute management is focused on stabilization and preventing imminent acts of suicide (e.g., by admitting the patient to a psychiatric institution). Once there is no longer an immediate risk of self-harm, underlying conditions and risk factors must be addressed (e.g., with treatment with antidepressants).

• Suicide: the act of intentionally ending one's own life
• Suicidality: feelings of suicidal ideation or intent, indicating a risk of suicide
• Suicidal behavior: any thoughts of or attempts to end one's own life ^[1][2]
• Suicide attempt: : a potentially injurious behavior intended to end one's own life that does not have a fatal outcome
• Suicidal ideation ^[1][3]
  • Passive suicidal ideation: thoughts of wanting to die that do not include preparatory behavior or intent
  • Active suicidal ideation: thoughts of or plans to intentionally end one's own life

Suicide

• Incidence ^[4]
  • There are ∼ 47,000 suicides every year in the US.
  • Suicide is the 10^th leading cause of death for all ages and the 2^nd leading cause in individuals 15–34 years of age.
• Age
  • Peak incidence: 45–64 years
  • Incidence significantly increases after age 15, with another significant increase after age 45. ^[4]
• Sex: ♂ > ♀ ^[5]
• Method: > 50% of suicides are by firearm. ^[6]

Suicide attempts

• Incidence ^[7]
  • > 1 million suicide attempts per year
  • ∼ 25 suicide attempts per suicide
• Age: Peak incidence is 15–19 years. ^[7]
• Sex: ♀ > ♂ ^[5]

Suicide deaths are more common in men, while suicide attempts are more common in women. ^[8]

Epidemiological data refers to the US, unless otherwise specified.

Risk factors ^[3][9][10]

Individual

• Age > 45 years ^[9]
• Cisgender male individuals ^[9]
• CNS disorders: epilepsy, traumatic brain injury
• Chronic and/or serious diseases (e.g., cancer, chronic pain) ^[10]

Psychosocial

• Previous suicide attempt (most important risk factor) ^[11]
• Family history of suicide, particularly childhood loss of a parent to suicide
• Psychiatric disorders, e.g. : ^[3]
  • Mood disorders: major depressive disorder, bipolar disorder
  • Anxiety
  • Schizophrenia spectrum disorders
  • Borderline personality disorder
  • Alcohol or substance use disorder
  • Eating disorders
  • Impulsive aggression
• Recent psychiatric hospitalization ^[11]
• History of adverse childhood experiences (e.g., child sexual abuse)
• History of sexual assault
• History of nonsuicidal self-injury ^[12]
• Access to lethal means (e.g., firearms)
• Major life events
• Socioeconomic disadvantage (e.g., unemployment, homelessness)
• Poor social support
• Unmarried
• Bullying, cyberbullying ^[13]

At-risk populations ^[9][10][11]

The following populations are at increased risk of suicide due to a variety of factors, including social isolation, access to lethal means, and/or higher rates of psychiatric disorders.

• LGBTQ+ community
• Rural communities
• Incarcerated individuals
• Professions with access to lethal means (e.g., health care providers, farmers)
• Non-Hispanic White, American Indian, and Alaska Native individuals

SAD PERSONS are at risk for suicide: Sex (male), Age (> 45 years), Depression, Previous suicide attempt, Ethanol/substance use, Rational thinking loss (psychosis), Sick (chronic disease), Organized plan (acquisition of weapons/tools), No spouse or social support, Stated intent.

The optimal approach to evaluating patients with increased suicide risk is unclear; follow local protocols and use a combination of clinical judgment, decision support tools, and specialist consultation. Appropriate care is decided following an evaluation of the imminent risk of suicide.

Approach ^[11]

• Identify patients at high risk of suicide, including:
  • Patients with positive screening for suicide (see “Screening”)
  • Patients with suicidal ideation
  • Clinical suspicion of suicidal behavior
• Perform a brief suicide safety assessment using decision support tools.
• Consult a mental health professional to perform a comprehensive suicide risk assessment as needed.
• Perform a focused medical assessment to determine stability for treatment in a psychiatric setting.

Brief suicide safety assessment ^[11]

Do not use decision support tools to rule out suicide risk; they are not a substitute for clinical judgment. ^[11]

• Description: a series of questions to assess suicide risk and guide next steps (e.g., inquiring about suicidal ideation, prior attempts at self-harm, social support, stressors)
• Decision support tools
  • Ask Suicide-Screening Questions (ASQ) brief suicide safety assessment
  • Columbia-Suicide Severity Rating Scale (C-SSRS)

Comprehensive suicide risk assessment

• Comprehensive suicide risk assessments are usually performed by a mental health professional.
• Assessment frameworks vary but generally include a detailed history, including suicidal ideation, intent, risk factors, and protective factors. ^[14]

Patient history

It may be necessary to involve the patient's family, caregivers, and/or friends to obtain a full history. Patient consent should be obtained first, but communication may proceed without consent if there is imminent danger to the patient or others. ^[11][15]

• Ask specifically and directly about suicidal ideation. ^[9]
• Assess whether there is a concrete intent or plan and whether the patient can act on it (e.g., possession of firearms).
• Ask about previous suicide attempts, including aborted attempts.
• Inquire about potential underlying conditions and contributing factors, including:
  • Psychiatric conditions (e.g., mood disorders, schizophrenia) and prior psychiatric care
  • Recent severe psychological stress and/or trauma
  • Alcohol and substance use
  • Medical conditions
  • Current medications
• Ask about protective factors (e.g., social contacts, strong reasons for living).

Confidentiality may need to be breached if there is clear evidence of imminent danger or harm to the patient or others. ^[11]

Unexpected, sudden improvement of symptoms in patients with depression and a high risk of suicide may indicate an imminent suicide plan. ^[16]

Focused medical assessment ^[11][15][17]

Assess the patient for concurrent medical issues and comorbid psychiatric conditions prior to discharge or transfer. This is commonly referred to as medical clearance.

• Perform a focused history and physical examination.
• Manage active medical issues, e.g.:
  • Injuries, including nonsuicidal self-injuries
  • Substance-induced disorders
  • Chronic medical conditions
• Assess for other psychiatric conditions using, e.g.:
  • Screening for depression
  • Evaluation and management of acute psychosis
  • Screening for unhealthy alcohol use
• Obtain targeted diagnostic studies as clinically indicated, e.g.:
  • Diagnostics for altered mental status
  • Evaluation of depressive disorder due to another medical condition or substance/medication-induced depressive disorder
• Obtain routine diagnostic studies required by receiving psychiatric facilities. ^[17]

Obtaining routine diagnostic studies in patients with a primary psychiatric concern who are otherwise healthy is unlikely (< 1% chance) to alter a patient's disposition. ^[18]

Suicide risk screening strategies ^[11]

Patients may be screened if their presenting concern indicates a potential suicide attempt, if they are in a high-risk group, or as part of a universal screening strategy.

• Indicated screening: patients with conditions or presentations that may indicate a suicide attempt
  • Poisoning
  • Lacerated wrists
  • Falls from height
  • Gunshot wounds
  • Motor vehicle collisions
• Selective screening: patients with risk factors for suicide
• Universal screening: all patients who interact with a health care provider (e.g., all patients who present to an emergency department)

The USPSTF found insufficient evidence for universal screening for suicide in children and adults, while the AAP recommends universal screening of all children and adolescents 12 years and older. ^[1][19][20]

Asking a patient directly about suicidal ideation does not increase the likelihood of a suicide attempt. ^[9]

Suicide risk screening tools ^[11][21]

Multiple validated screening tools have been developed to identify patients at risk for suicide. Given limited evidence to support the use of one tool over another, follow local protocols when screening for suicide risk. ^[21]

• Columbia-Suicide Severity Rating Scale (C-SSRS)
• Patient Health Questionnaire-9
• ASQ suicide risk screening tool

ASQ suicide risk screening tool ^[22]

• Ask the patient about:
  • Recent wishes to be dead
  • Recent thoughts about the patient or their family being better off if they were dead
  • Recent thoughts about suicide
  • Past suicide attempts
• Interpretation and next steps:
  • “No” to all of the above: The screen is considered negative.
  • “Yes” to any of the above: Ask a fifth question on current thoughts of suicide.
    • If “no”: Evaluate further with a brief suicide safety assessment.
    • If “yes”: Initiate safety precautions for patients at risk of suicide and further psychiatric evaluation.

Nonsuicidal self-injury (NSSI) ^[11][23]

• Definition: the intentional infliction of harm or pain on oneself (e.g., cutting, burning, excessive scratching, hitting) without suicidal intent
• Epidemiology
  • Highest prevalence in adolescents ^[24]
  • Increased prevalence in child and adolescent psychiatric inpatients ^[24]
• Etiology
  • Psychiatric conditions (e.g., borderline personality disorder, eating disorders, major depressive disorder)
  • Environmental factors (e.g., adverse childhood experiences, negative peer influences, disrupted attachment)
• Clinical features: depend on the type of self-injury
  • Patients may present with acute injuries (e.g., open wounds, burns).
  • Patterns of scars from previous self-injuries (e.g., parallel cutting or grouped scars from cigarette burns)
• Diagnosis
  • Primarily clinical
  • Screen for suicidal intent in all individuals presenting with suspected NSSI.
• Differential diagnoses: sexual violence, intimate partner violence, older adult abuse, suicide attempts
• Treatment ^[23][25]
  • Ensure that all providers use nonjudgmental communication.
  • Acute management depends on the type of injury, e.g., wound treatment or treatment of burns.
  • Assess for and initiate treatment of underlying psychiatric disorders, e.g., treatment of depression.
  • Further management depends on the risk of severe injury and suicidal behavior.
    • Confidentiality may need to be breached (e.g., by informing the parents of a minor about the behavior) if there is a risk of suicide or continued or severe injury.
    • Psychotherapy may be indicated if there is repetitive and/or dangerous self-harm behavior (e.g., inflicting wounds that require medical attention).
    • Potential treatments include cognitive behavioral therapy and dialectical behavioral therapy.

Rule out suicidal ideation in all patients presenting with intentional self-injury.

Other differential diagnoses ^[11]

• Unintentional self-injury
• Unintentional ingestion
• Malingering
• Colloquialisms

The differential diagnoses listed here are not exhaustive.

Approach ^[11]

• Begin immediate stabilization using the ABCDE approach and manage intoxication and injuries. See:
  • “ABCDE approach in poisoning”
  • “Management of trauma patients”
  • “Acute wound management”
• Initiate safety precautions for patients at risk of suicide.
• Consult psychiatry for further help (e.g., transfer to a psychiatric facility, inpatient evaluation) if patients require a comprehensive suicide risk assessment. ^[15]
• Determine a safe disposition.

Safety precautions for patients at risk of suicide ^[11][15]

• Establish close monitoring; do not leave the patient alone.
• Ensure that the patient is not carrying any weapons or other potentially lethal items (e.g., a belt).
• Remove all potentially dangerous items from the patient's room (e.g., sharp instruments, glass).
• Manage agitation, ideally without calming medication or restraints.

Disposition ^[9][11]

Use a combination of clinical judgment, decision support tools, and specialist consultation to determine appropriate disposition.

Psychiatric hospitalization

• Indicated for all patients with thoughts of suicide and a concrete plan and/or other high-risk features (e.g., substance use disorder, lack of a support system, access to lethal means)
• Voluntary admission is preferred, but involuntary commitment may be necessary if the patient is uncooperative and there is evidence of immediate danger to themselves or others.
• For pediatric patients, involuntary commitment may be necessary if the parents are unavailable or do not consent.
• Ensure that all medical and surgical problems have been addressed before transfer (e.g., closure of acute open wounds).

Medical hospitalization

• May be necessary to treat underlying or concurrent medical problems (e.g., substance intoxication or withdrawal)
• Continue safety precautions for patients at risk of suicide until cleared by psychiatry.

Discharge

• May be considered for patients with suicidal ideation if the risk of suicide is deemed low (e.g., no concrete plan, good support system, presence of protective factors)
• When in doubt, consult a mental health professional before discharge.
• With patient consent, involve close contacts to ensure discharge to a safe environment.
• Discharge planning should include: ^[1][11][15]
  • Patient education: e.g., on individual warning signs, protective factors, and necessary follow-up
  • Safety planning: formulating a plan for future crises together with the patient, including coping strategies and who to reach out to.
  • Lethal means counseling: e.g., recommending the removal of firearms or prescription medications
  • Referral for follow-up, ideally within 72 hours ^[11]
  • Asking close contacts to check on the patient, e.g., with a text message

If there is any doubt about whether a patient is at risk of suicide, consult a mental health professional before discharge. ^[11]

Counsel patients at risk for suicide and their families to remove firearms from the home. ^[11]

Long-term management of patients with thoughts of suicide mainly involves treating the underlying psychiatric disorder, counseling, and frequent follow-ups.

Pharmacological treatement ^[9][10]

Consider the following pharmacological treatment for underlying psychiatric conditions.

• Major depressive disorder
  • SSRIs; : can initially increase energy and motivation, which may increase suicidal behavior; in adolescents and young adults, especially within the first few months of treatment ^[1]
  • Tricyclic antidepressants, MAO inhibitors, venlafaxine: not preferred due to higher toxicity in overdose ^[26]
  • See “Management of major depressive disorder.”
• Bipolar disorder
  • Mood stabilizers: e.g., lithium, valproic acid
  • See “Management of bipolar disorder.”
• Schizophrenia
  • Antipsychotics: e.g., risperidone, aripiprazole
  • See “Management of schizophrenia.”

Lithium has been shown to reduce suicide rates in patients with major depressive disorder and bipolar disorder. ^[10]

As antidepressants such as SSRIs can increase energy and motivation before an improvement in mood occurs, the risk of suicide may increase during the first weeks of treatment. Close observation and frequent follow-ups are vital! ^[1]

Nonpharmacological treatment ^[9][21]

• Psychotherapeutic interventions ^[10]
  • Cognitive behavioral therapy
  • Dialectical behavioral therapy
  • Mindfulness-based cognitive therapy
• Counseling, e.g.:
  • Improvement of social circumstances; that constitute risk factors for suicidal behavior (e.g., changing living conditions and increasing social contacts and a sense of connectedness)
  • Development of; personal skills that have a protective effect (e.g., problem-solving and coping skills; ) and encouraging reflection about religious and/or cultural beliefs to promote a sense of purpose

• One-Minute Telegram 110-2024-3/3: Suicide prevention: integrating care beyond the crisis
• One-Minute Telegram 61-2022-3/3: Fluoroquinolones are not associated with increased suicidality
• One-Minute Telegram 4-2020-2/3: The other epidemic: handgun ownership and suicidality

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