II. Epidemiology

  1. Incidence in U.S.
    1. Suicidal Ideation is present in up to 8% of Emergency Department patients
    2. Suicide rates increased 20-30% between 2005 and 2015
    3. Deaths in U.S. (2017): 47,000
    4. Ages 5-11 years: 0.1 per 100,000
      1. Overall suicide Incidence has not changed for ages 5-11 between 1993 and 2012
      2. However Incidence has increased in black children, and decreased in white children
      3. Bridge (2015) JAMA Pediatr 169(7): 67307 [PubMed]
    5. Ages 10-74 years: 13 per 100,000
      1. Suicide rate increased 25% from 10.5 per 100,000 in 1999, to 13 per 100,000 in 2014
      2. Highest Suicide rate increase was for age 10-14 in females, and age 45-64 in males
  2. Gender
    1. Women are twice as likely as men to attempt Suicide
    2. Men are four times more likely to die of Suicide
  3. Age
    1. Highest Suicide rates have been in ages 45-54 years, and 75-84 years historically
    2. Highest rates of Suicidal Ideation, planning and attempts occurs in ages 18 to 25 years
    3. Suicide in the second leading cause of death in ages 10 to 34 years old
  4. Most common methods of completed Suicide
    1. Children
      1. Suffocation by hanging (belt or electric cord)
    2. Adolescents and Adults
      1. Firearms (50%, esp. males)
      2. Hanging or Suffocation (28%, esp. males)
      3. Medication Overdose or Poisoning (14%, esp. females)
  5. References
    1. Increase in Suicide in the U.S. from 1999 to 2014 (CDC)
      1. https://www.cdc.gov/nchs/products/databriefs/db241.htm
    2. National Suicide Statistics (CDC)
      1. https://www.cdc.gov/violenceprevention/suicide/statistics/

III. Risk Factors

  1. Current mental status
    1. Agitation
    2. Anxiety
    3. Insomnia
  2. Biologic factors
    1. Age 20 to 24 and over age 65 years
    2. Native American or native alaskan
    3. Caucasian
    4. Male gender (especially elderly male)
  3. Psychiatric factors
    1. Psychosis or Psychotic symptoms
      1. Highest risk with command Hallucinations (Hallucinations that instruct self harm)
    2. Impulsive Behavior
    3. Previous Suicide attempt within last 2 years
      1. Highest risk for adolescent Suicide is a prior attempt
    4. Family History of completed Suicide
    5. Major Depression symptoms
      1. Anhedonia
      2. Hopelessness
      3. Insomnia
      4. Irritability
    6. Personality Disorders (associated with increased suicidal gestures, with risk of lethality)
      1. Borderline Personality Disorder
      2. Histrionic Personality disorder
      3. Narcissistic Personality disorder
    7. Comorbid mental illness
      1. Substance Abuse
        1. Alcohol Dependence is associated with 9 fold increased Suicide Risk
        2. Acute Alcohol Intoxication substantially increases Suicide Risk
          1. One third of attempted Suicide patients drink Alcohol before attempt
      2. Major Depression
      3. Severe Anxiety Disorder (including PTSD)
      4. Bipolar Disorder
      5. Schizophrenia
  4. Social factors
    1. Solitary lifestyle or limited social support (e.g. divorced or widowed patient)
    2. Homosexual or Transgender identity
    3. Available lethal means to carry out a Suicide plan (e.g. weapons in home)
    4. Rural residence
    5. Stressful life event or recent acute psychosocial stressors ("tipping points")
      1. Relationship problems
      2. Financial or legal trouble
      3. Public humiliation or shame
    6. Suicide "contagion" in teenagers
      1. Completed Suicide in others (at school, in media), may increase Suicidality risk in others
      2. Highest risk among other children with depressed mood or social isolation
  5. Comorbid medical conditions
    1. Associated chronic medical condition (e.g. COPD, Chronic Pain, Traumatic Brain Injury)
    2. Seizure Disorder (3 fold higher risk)
    3. Medications associated with increased Suicidal Ideation
      1. See Suicidality Associated with Medications

IV. Precautions

  1. Be alert for depressed mood in all patients
  2. Inquire about suicidal thoughts in depression
    1. Asking about Suicide does not increase its risk
    2. Guns
    3. Poisoning
    4. Hanging
  3. Protect the patient and staff during evaluation
    1. Keep patient under one-to-one observation during acute Suicidality evaluation
    2. Remove any items of potential self-harm (belts, shoelaces, sharp instruments)
    3. Secure purses and other belongings
    4. Emergency department patients change into scrub-like clothing
  4. Establish a therapeutic alliance
    1. Explain the anticipated course of evaluation
    2. Express empathy
    3. Provide basic comforts (e.g. food and drink)
    4. Attempt Verbal De-escalation before use of Chemical Restraints

V. Evaluation: General

  1. See Emergency Psychiatric Evaluation
  2. Patient must be alert, Clinically Sober and cooperative for adequate evaluation
    1. Clinical sober patients should have normal coordination, cognition and a lack of emotional lability
      1. No specific number defines Clinical Sobriety
  3. Consider screening tools
    1. Ask Suicide-Screening Questions (ASQ Suicide Screening Test)
    2. Columbia Suicide Severity Rating Scale (C-SSRS)
  4. Avoid confrontational approach
    1. Obtain patient comfort and trust first
    2. Maintain culturally sensitive approach
    3. Maintain good eye contact
  5. Sample questioning method:
    1. Have there been recent CHANGES with family, friends, home or work?
    2. What are your plans for the FUTURE?
    3. Do you ever lose HOPE with your current situation?
    4. What do you THINK ABOUT when feeling down?
    5. Are you IMPULSIVE in your decisions or behavior?
    6. Do you ever consider Running AWAY from your problems?
    7. Have you had DEPRESSION, ANXIETY or OTHER mental illness in the past?
    8. Have you ever thought of HURTING yourself?
    9. Have you ever thought of KILLING yourself?
    10. How have you PLANNED to kill yourself?
    11. Have you PREPARED to do this?
    12. Has any FAMILY MEMBER attempted Suicide in the past?
    13. Have YOU ever attempted Suicide in the past?
    14. Are you CURRENTLY thinking about death or harming yourself?
    15. Do you use Alcohol or Illicit DrugS?
    16. Do you make IMPULSIVE decisions or actions?
    17. Do you have WEAPONS, POISONS in PILLS at home you would use to harm yourself?
    18. Have you shared your self-harm thoughts with OTHERS?
    19. Do you have FRIENDS or FAMILY with whom you are close?
    20. What would happen to your FAMILY without you?
    21. What has PREVENTED you from committing Suicide?
  6. References
    1. Norris (2012) Am Fam Physician 85(6): 602-5 [PubMed]
    2. Stovall (2003) Am Fam Physician 68(9):1814-8 [PubMed]

VI. Evaluation: Risk Assessment

  1. See Modified MSPS Suicide Risk Assessment (Modified SAD PERSONS)
  2. Precautions
    1. Defining low risk is challenging and despite best efforts, half of low risk stratified patients go on to Suicide
      1. Large (2017) BMJ 359: j4627 +PMID:29042363 [PubMed]
    2. Suicidal gestures may progress to lethality
      1. Take each suicidal gesture seriously, addressing risks (esp. in Personality Disorder)
  3. Static or Stable Risks
    1. History of mental illness (especially newly diagnosed)
    2. Chemical Addiction
    3. Personality Disorder
    4. Teenagers and the elderly (esp. white elderly males)
    5. Prior Suicide attempts (high risk)
    6. Family History of completed Suicide attempts
    7. Gay, lesbian, Transgender or bisexual youth
  4. High Risk Dynamic factors
    1. Prepared or attempted with highly lethal means (guns or hanging)
    2. Planned or rehearsed Suicide in advance
    3. Attempts to avoid discovery of suicidal plans (e.g. at remote location)
    4. Suicide note left to put affairs in order
    5. Anger in response to failed Suicide attempt
    6. Subjective belief in the high lethality of their attempt (regardless of the actual lethality)
  5. Moderate Risk Dynamic factors
    1. Use of limited number of medications or illicit substances in Suicide attempt
    2. Suicide attempt in location with high chance of discovery (or calling for help)
    3. Suicide note with overly manipulative or attention-getting language
  6. Low Risk Dynamic factors
    1. Small number of pills taken
    2. Suicide attempt in front of another person
    3. Glad that Suicide attempt was unsuccessful
  7. Protective Factors
    1. Strong social support system (friends, family)
    2. Expressed reasons for living
      1. Optimism about life
      2. Family responsibility (esp. to children)

VII. Management

  1. See Emergency Psychiatric Evaluation
  2. Involve a mental health specialist in disposition
  3. Manage acute medical complications from attempted Suicide
    1. See Unknown Ingestion
    2. See Near-Hanging
    3. See Penetrating Trauma
    4. Suicide techniques are described online (Suicide kits) with directions on self injury cocktails
      1. Always consider Acetaminophen Poisoning and Salicylate Poisoning
      2. Sodium Nitrite Poisoning
        1. Presents with Methemoglobinemia, Tachypnea, Altered Level of Consciousness, Seizures
      3. Carbon Monoxide Poisoning
        1. Results from ingestion of formic acid and sulfuric acid (sulphuric acid)
      4. Hydrogen Sulfide Poisoning
        1. Acid (e.g. toilet bowl cleaner) combined with sulfur-containing molecule (e.g. Pesticides, fungicide)
      5. Carbon Dioxide Poisoning
        1. Citric acid and Baking Soda inhaled with head in a bag, while in an enclosed space
      6. References
        1. Swadron and Nordt (2022) EM:Rap 22(6): 5-7
  4. Hospitalize imminently suicidal patients
    1. High risk dynamic factors present (see above)
    2. Attempt was violent, near-lethal or premeditated
    3. Persistent plan or intent to die is present
    4. Unable or unwilling to follow a safety plan
    5. Severe hopelessness
    6. Limited family or social support or unstable living situation
    7. Impulsive behavior, severe Agitation, Psychosis, poor judgement or refusing help
    8. Unreliable for follow-up or monitoring
    9. Alterered mental status (acute Delirium) requires additional workup and medical monitoring
  5. Evaluate patient home safety
    1. Patient has decision making capacity
    2. Patient has the ability for adequate self care
    3. Remove all lethal means and weapons from the home, especially firearms (90% fatality rate)
      1. Store firearms outside the home (locked, unloaded and separate from ammunition)
      2. Also remove knives and medications that might be used for Suicide
    4. Family and friend involvement is critical
    5. Patient will cooperate with treatment plan and implementation including close interval follow-up
  6. Treat underlying psychiatric illness
    1. See Depression Management
    2. Treat Substance Abuse
    3. Instill hope that this will get better
    4. Reduce the shame and stigma associated with mental health crisis
    5. Initiate psychological counseling with rapid referral to outpatient psychiatric care (within 7 days)
    6. Lithium reduces Suicide Risk and mortality in Bipolar Disorder (as well as unipolar depression)
    7. Exercise caution in adolescents and young adults on Selective Serotonin Reuptake Inhibitors (SSRI)
      1. SSRI has been associated with increased Suicidality in first few months after starting medication
      2. Limit prescriptions to 30 day supply and schedule frequent visits and phone calls
      3. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/suicidality-children-and-adolescents-being-treated-antidepressant-medications
  7. Establish an outpatient printed safety plan
    1. Contrast the Safety Plan with the "contract for safety" which is no longer recommended
    2. Recognize Suicide warning signs
    3. Identify coping strategies
    4. Social support and social safety net (e.g. family, close friends, other medical providers)
    5. Crisis contacts
      1. Family or mental health
      2. Local crisis resources, local emergency department or 911
      3. Suicide call or text line (988)
    6. Remove access to lethal means of Suicide (e.g. medications, firearms)
      1. Some U.S. States have specific Red Flag laws
    7. Form Template
      1. https://suicidepreventionlifeline.org/wp-content/uploads/2016/08/Brown_StanleySafetyPlanTemplate.pdf

VIII. Prevention

  1. Talk about Suicide with children, teenagers and adults
    1. Talking about Suicide does not increase its risk
    2. Screening does not increase Suicide Risk
  2. Family members and friends should be aware of the warning signs of Major Depression and Suicidality
    1. See Psychological First Aid
    2. Social isolation or withdrawn
    3. Increased stressors (see Risk Factors above)
  3. Review safety plans for Suicidality (see above)
    1. Safe places with school, family or friends
    2. Emergency department evaluation
    3. Suicide Hotline

IX. Complications: Completed Suicide

  1. Address Bereavement in surviving family members
  2. Anticipate the self-blame and shame that the surviving family may feel
  3. Offer support services

X. Resources

  1. American Foundation for Suicide Prevention
    1. https://afsp.org
  2. Suicide Prevention Resource Center
    1. https://www.sprc.org/
  3. Columbia Suicide Severity Rating Scale (C-SSRS)
    1. http://www.cssrs.columbia.edu/
  4. Suicide and Crisis Lifeline (National Suicide Prevention Lifeline)
    1. https://988lifeline.org/
    2. Text: 988
    3. Phone: 800-273-TALK (8255)
  5. Crisis Text Line
    1. Text "HOME" to 741741

XI. References

  1. Grover and Onyinyechi (2021) Crit Dec Emerg Med 35(3): 3-7
  2. Horning and White (2020) Crit Dec Emerg Med 34(2): 3-10
  3. Wang (2018) Crit Dec Emerg Med 32(5):15
  4. Weingart, Pallaci, Bridge and Stout in Herbert (2017) EM:Rap 17(11): 12-13
  5. Hamilton (2000) Postgrad Med 108(6):81-7 [PubMed]
  6. Hirschfeld (1997) N Engl J Med 337(13): 910-5 [PubMed]
  7. Maris (2002) Lancet 360(9329):319-26 [PubMed]
  8. (2004) Ann Intern Med 140(10): 820-1 [PubMed]
  9. Norris (2012) Am Fam Physician 85(6): 602-5 [PubMed]
  10. Sall (2019) Ann Intern Med 171(5): 343-53 [PubMed]
  11. Stovall (2003) Am Fam Physician 68(9):1814-8 [PubMed]

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