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Suicide
Aka: Suicide, Suicide Risk, Suicide Risk Factors, Suicidality, Suicidal Ideation, Suicide Screening, Suicide Prevention, Suicidality Safety Plan
- See Also
- Emergency Psychiatric Evaluation
- Major Depression
- Ask Suicide-Screening Questions (ASQ Suicide Screening Test)
- Columbia Suicide Severity Rating Scale (C-SSRS)
- Modified MSPS Suicide Risk Assessment
- Epidemiology
- Incidence in U.S.
- Ages 5-11 years: 0.1 per 100,000
- Overall suicide Incidence has not changed for ages 5-11 between 1993 and 2012
- However Incidence has increased in black children, and decreased in white children
- Bridge (2015) JAMA Pediatr 169(7): 67307 [PubMed]
- Ages 10-74 years: 13 per 100,000
- Suicide rate increased 25% from 10.5 per 100,000 in 1999, to 13 per 100,000 in 2014
- Highest Suicide rate increase was for age 10-14 in females, and age 45-64 in males
- Most common methods of Suicide
- Children
- Suffocation by hanging (belt or electric cord)
- Adolescents and Adults
- Males: Firearms
- Females: Poisoning
- References
- Increase in Suicide in the U.S. from 1999 to 2014 (CDC)
- https://www.cdc.gov/nchs/products/databriefs/db241.htm
- National Suicide Statistics (CDC)
- https://www.cdc.gov/violenceprevention/suicide/statistics/
- Risk Factors
- Current mental status
- Agitation
- Anxiety
- Insomnia
- Biologic factors
- Age 20 to 24 and over age 65 years
- Native American or native alaskan
- Caucasian
- Male gender (especially elderly male)
- Psychiatric factors
- Psychosis or Psychotic symptoms
- Impulsive Behavior
- Previous Suicide attempt within last 2 years
- Highest risk for adolescent Suicide is a prior attempt
- Family History of completed Suicide
- Major Depression symptoms
- Anhedonia
- Hopelessness
- Insomnia
- Irritability
- Comorbid mental illness
- Substance Abuse
- Alcohol Dependence is associated with 9 fold increased Suicide Risk
- Acute Alcohol Intoxication substantially increases Suicide Risk
- One third of attempted Suicide patients drink Alcohol before attempt
- Major Depression
- Severe Anxiety Disorder (including PTSD)
- Bipolar Disorder
- Schizophrenia
- Borderline Personality disorder
- Social factors
- Solitary lifestyle or limited social support (e.g. divorced or widowed patient)
- Homosexual or Transgender identity
- Available lethal means to carry out a Suicide plan (e.g. weapons in home)
- Stressful life event or recent acute psychosocial stressors ("tipping points")
- Relationship problems
- Financial or legal trouble
- Public humiliation or shame
- Suicide "contagion" in teenagers
- Completed Suicide in others (at school, in media), may increase Suicidality risk in others
- Highest risk among other children with depressed mood or social isolation
- Comorbid medical conditions
- Associated chronic medical condition
- Seizure disorder (3 fold higher risk)
- Medications associated with increased Suicidal Ideation
- See Suicidality Associated with Medications
- Precautions
- Be alert for depressed mood in all patients
- Inquire about suicidal thoughts in depression
- Asking about Suicide does not increase its risk
- Guns
- Poisoning
- Hanging
- Protect the patient and staff during evaluation
- Keep patient under one-to-one observation during acute Suicidality evaluation
- Remove any items of potential self-harm (belts, shoelaces, sharp instruments)
- Secure purses and other belongings
- Emergency department patients change into scrub-like clothing
- Evaluation: General
- See Emergency Psychiatric Evaluation
- Patient must be alert, Clinically Sober and cooperative for adequate evaluation
- Clinical sober patients should have normal coordination, cognition and a lack of emotional lability
- No specific number defines Clinical Sobriety
- Consider screening tools
- Ask Suicide-Screening Questions (ASQ Suicide Screening Test)
- Columbia Suicide Severity Rating Scale (C-SSRS)
- Avoid confrontational approach
- Obtain patient comfort and trust first
- Maintain culturally sensitive approach
- Maintain good eye contact
- Sample questioning method:
- Have there been recent CHANGES with family, friends, home or work?
- What are your plans for the FUTURE?
- Do you ever lose HOPE with your current situation?
- What do you THINK ABOUT when feeling down?
- Do you ever consider Running AWAY from your problems?
- Have you had DEPRESSION, ANXIETY or OTHER mental illness in the past?
- Have you ever thought of HURTING yourself?
- Have you ever thought of KILLING yourself?
- How have you PLANNED to kill yourself?
- Have you PREPARED to do this?
- Has any FAMILY MEMBER attempted Suicide in the past?
- Are you CURRENTLY thinking about death or harming yourself?
- Do you use Alcohol or DRUGS?
- Do you make IMPULSIVE decisions or actions?
- Do you have WEAPONS, POISONS in PILLS at home you would use to harm yourself?
- Have you shared your self-harm thoughts with OTHERS?
- Do you have FRIENDS or FAMILY with whom you are close?
- What would happen to your FAMILY without you?
- What has PREVENTED you from committing Suicide?
- References
- Norris (2012) Am Fam Physician 85(6): 602-5 [PubMed]
- Stovall (2003) Am Fam Physician 68(9):1814-8 [PubMed]
- Evaluation: Risk Assessment
- See Modified MSPS Suicide Risk Assessment (Modified SAD PERSONS)
- Static or Stable Risks
- History of mental illness (especially newly diagnosed)
- Chemical Addiction
- Personality Disorder
- Teenagers and the elderly (esp. white elderly males)
- Prior Suicide attempts (high risk)
- Family History of completed Suicide attempts
- Gay, lesbian, Transgender or bisexual youth
- High Risk Dynamic factors
- Prepared or attempted with highly lethal means (guns or hanging)
- Planned or rehearsed Suicide in advance
- Attempts to avoid discovery of suicidal plans (e.g. at remote location)
- Suicide note left to put affairs in order
- Anger in response to failed Suicide attempt
- Subjective belief in the high lethality of their attempt (regardless of the actual lethality)
- Moderate Risk Dynamic factors
- Use of limited number of medications or illicit substances in Suicide attempt
- Suicide attempt in location with high chance of discovery (or calling for help)
- Suicide note with overly manipulative or attention-getting language
- Low Risk Dynamic factors
- Small number of pills taken
- Suicide attempt in front of another person
- Glad that Suicide attempt was unsuccessful
- Protective Factors
- Strong social support system (friends, family)
- Expressed reasons for living
- Optimism about life
- Family responsibility (esp. to children)
- Management
- See Emergency Psychiatric Evaluation
- Hospitalize imminently suicidal patients
- High risk dynamic factors present (see above)
- Attempt was violent, near-lethal or premeditated
- Persistent plan or intent to die is present
- Unable or unwilling to follow a safety plan
- Severe hopelessness
- Limited family or social support or unstable living situation
- Impulsive behavior, severe Agitation, Psychosis, poor judgement or refusing help
- Unreliable for follow-up or monitoring
- Alterered mental status (acute Delirium) requires additional workup and medical monitoring
- Evaluate patient home safety
- Patient has decision making capacity
- Patient has the ability for adequate self care
- Remove all weapons in the home, especially firearms (90% fatality rate)
- Store firearms outside the home (locked, unloaded and separate from ammunition)
- Also remove knives and medications that might be used for Suicide
- Family and friend involvement is critical
- Patient will cooperate with treatment plan and implementation including close interval follow-up
- Treat underlying psychiatric illness
- See Depression Management
- Treat Substance Abuse
- Initiate psychological counseling with rapid referral to outpatient psychiatric care
- Establish an outpatient printed safety plan
- Contrast the Safety Plan with the "contract for safety" which is no longer recommended
- Recognize Suicide warning signs
- Identify coping strategies
- Crisis contacts (family or mental health)
- Form Template
- https://suicidepreventionlifeline.org/wp-content/uploads/2016/08/Brown_StanleySafetyPlanTemplate.pdf
- Prevention
- Talk about Suicide with children, teenagers and adults
- Talking about Suicide does not increase its risk
- Family members and friends should be aware of the warning signs of Major Depression and Suicidality
- Social isolation or withdrawn
- Review safety plans for Suicidality (see above)
- Safe places with school, family or friends
- Emergency department evaluation
- Suicide Hotline
- Resources
- American Foundation for Suicide Prevention
- http://www.afsp.org
- National Suicide Prevention Lifeline
- http://www.suicidepreventionlifeline.org
- Phone: 800-273-TALK
- Suicide Prevention Resource Center
- http://www.sprc.org
- Columbia Suicide Severity Rating Scale (C-SSRS)
- http://www.cssrs.columbia.edu/
- Crisis Text Line
- Text "HOME" to 741741
- References
- Grover and Onyinyechi (2021) Crit Dec Emerg Med 35(3): 3-7
- Horning and White (2020) Crit Dec Emerg Med 34(2): 3-10
- Weingart, Pallaci, Bridge and Stout in Herbert (2017) EM:Rap 17(11): 12-13
- Hamilton (2000) Postgrad Med 108(6):81-7 [PubMed]
- Hirschfeld (1997) N Engl J Med 337(13): 910-5 [PubMed]
- Maris (2002) Lancet 360(9329):319-26 [PubMed]
- (2004) Ann Intern Med 140(10): 820-1 [PubMed]
- Norris (2012) Am Fam Physician 85(6): 602-5 [PubMed]
- Stovall (2003) Am Fam Physician 68(9):1814-8 [PubMed]