Suicide, Suicide Risk, Suicidality, Suicidal Ideation, Suicide Screening

  • Epidemiology
  1. Incidence in U.S.
    1. 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]
    2. 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. Most common methods of Suicide
    1. Children
      1. Suffocation by hanging (belt or electric cord)
    2. Adolescents and Adults
      1. Males: Firearms
      2. Females: Poisoning
  3. References
    1. Increase in Suicide in the U.S. from 1999 to 2014 (CDC)
    2. National Suicide Statistics (CDC)
  • 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. Psychotic symptoms
    2. Previous Suicide attempt within last 2 years
    3. Family History of completed Suicide
    4. Major Depression symptoms
      1. Anhedonia
      2. Hopelessness
      3. Insomnia
      4. Irritability
    5. Comorbid mental illness
      1. Substance Abuse
      2. Major Depression
      3. Severe Anxiety Disorder (including PTSD)
      4. Bipolar Disorder
      5. Schizophrenia
      6. Borderline Personality disorder
  4. Social factors
    1. Solitary lifestyle or limited social support (e.g. divorced or widowed patient)
    2. Available means to carry out a Suicide plan (e.g. weapons in home)
    3. Stressful life event
    4. 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
    2. Seizure disorder (3 fold higher risk)
    3. Medications associated with increased Suicidal Ideation
      1. See Suicidality Associated with Medications
  • 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
  • Evaluation
  • General
  1. See Ask Suicide-Screening Questions (ASQ Suicide Screening Test)
  2. Avoid confrontational approach
    1. Obtain patient comfort and trust first
    2. Maintain culturally sensitive approach
    3. Maintain good eye contact
  3. 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. Do you ever consider Running AWAY from your problems?
    6. Have you had DEPRESSION, ANXIETY or OTHER mental illness in the past?
    7. Have you ever thought of HURTING yourself?
    8. Have you ever thought of KILLING yourself?
    9. How have you PLANNED to kill yourself?
    10. Have you PREPARED to do this?
    11. Has any FAMILY MEMBER attempted Suicide in the past?
    12. Are you CURRENTLY thinking about death or harming yourself?
    13. Do you use Alcohol or DRUGS?
    14. Do you make IMPULSIVE decisions or actions?
    15. Do you have WEAPONS, POISONS in PILLS at home you would use to harm yourself?
    16. Have you shared your self-harm thoughts with OTHERS?
    17. Do you have FRIENDS or FAMILY with whom you are close?
    18. What would happen to your FAMILY without you?
    19. What has PREVENTED you from committing Suicide?
  4. References
    1. Norris (2012) Am Fam Physician 85(6): 602-5 [PubMed]
    2. Stovall (2003) Am Fam Physician 68(9):1814-8 [PubMed]
  • Evaluation
  • Risk Assessment
  1. 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
    6. Family History of completed Suicide attempts
    7. Gay, lesbian, Transgender or bisexual youth
  2. 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
  3. 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
  4. 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
  • Management
  1. Evaluate patient safety
    1. Hospitalize imminently suicidal patients (especially with high risk dynamic factors)
    2. Remove all weapons in the home
    3. Family and friend involvement is critical
  2. Treat underlying psychiatric illness
    1. See Depression Management
    2. Treat Substance Abuse
    3. Initiate psychological counseling
  • Resources
  1. American Foundation for Suicide Prevention
  2. National Suicide Prevention Lifeline
    2. Phone: 800-273-TALK
  3. Suicide Prevention Resource Center
  4. Columbia Suicide Severity Rating Scale (C-SSRS)
  5. Crisis Text Line
    1. Text "HOME" to 741741
  • Prevention
  1. Talk about Suicide with children, teenagers and adults
    1. Talking about Suicide does not increase its risk
  2. Family members and friends should be aware of the warning signs of Major Depression and Suicidality
    1. Social isolation or withdrawn
  3. Review safety plans for Suicidality
    1. Safe places with school, family or friends
    2. Emergency department evaluation
    3. Suicide Hotline