• Information
  1. Epidemiology
  2. Identification of Potential Suicides
  3. Management
  4. Depression and Suicide
  5. Manage Your Liability Exposure

A. Epidemiology

1. General
   1. Overall rate of suicide = 11.2 per 100,000 people per year, or 31,000 deaths per year
   2. Suicidal ideation is common with a lifetime incidence of ~30% of general population
   3. Ratio of attempted suicide to successful suicides = 18:1
   4. Up to 2/3 of patients who commit suicide saw a doctor in the month preceding death
2. Gender and Race
   1. Women attempt suicide more often than men
   2. Men are more likely to succeed
   3. Men commit suicide 4 times more often than women
   4. 73% suicides committed by white men
   5. Suicide rate is highest among white men over 69 years
   6. Among people < 45 years, suicide is the fifth leading cause of death
   7. Suicide is more common in people >45 years than <30 years
   8. Whites and Native Americans are at high risk to commit suicide
   9. African Americans, Asians and Hispanics are at lower risk
3. Adolescents [4]
   1. Suicide is strongly associated with depression in adolescents
   2. Girls more likely to attempt suicide than boys
   3. Boys more likely to commit suicide than girls
   4. Suicide rates 15-19 year olds 14.6/100,000 boys, 2.9/100,000 girls
4. Nonclinical Risk Factors for Attempted and Completed Suicide
   1. Widowed or divorced
   2. Living alone
   3. Unemployment or financial problems
   4. Recent stressful life event: job loss, death of spouse or child
   5. However, strongest predictor of suicide is psychiatric illness
   6. 90% of suicides have a diagnosable psychiatric disorder at time of death
5. Major Psychiatric Risk Factors
   1. Clinical depression, bipolar disorder [2], schizophrenia
   2. Substance (including alcohol) abuse
   3. Combination depression and substance abuse especially strong predictor
   4. History of suicide attempts or ideation (greatest risk factor)
   5. Feelings of hopelessness
   6. Panic attacks
   7. Severe anxiety, especially combined with depression
   8. Severe anhedonia
   9. History of violence
   10. Lifetime prevalence of suicide in schizophrenia ~10% [5]
6. Risk Factors for Attempted Suicide
   1. Female
   2. Age 30 years or less
   3. Perceived threat to intimate relationship
   4. Clinical depression or personality disorder
   5. Substance Abuse
   6. Schizophrenia [5]
7. Common Methods of Committing Suicide
   1. Firearms account for 60% of deaths by suicide
   2. Poisoning, the method preferred by women, is next most common method
   3. Men who don't use firearms are likely to hang themselves
8. Most Common Overdoses In Suicide [8]
   1. Analgesics: acetaminophen, ibuprofen, opiates
   2. Sedative / Hypnotic Agents: benzodiazepines, others
   3. Antipsychotic Agents
   4. Antidepressants
   5. Stimulants (including "street drugs")
   6. Cardiovascular agents

B. Identification of Potential Suicides [7]

1. Patients will not usually present with suicidal ideation
2. May present with vague somatic complaints - gastrointestinal problems, headache, fatigue
3. Establish sociodemographic information, including stressors
4. Screen for depression and associated anxiety or agitation
5. Screen for substance abuse
6. When risk factors present and/or patient expresses despair, hopelessness, or pessimism about the future, ask if he or she has considered suicide.
7. "Have you had thoughts about death, or about killing yourself?"
8. Asking patients if they have considered suicide will not "plant the idea in their head"
9. If patients admits to having considered suicide, ask the following questions:
   1. "Have you tried to commit suicide before?"
   2. "Has anyone in your family commited suicide?"
   3. "Do you have a plan for how you would do this?"
   4. "Are there means available for you to carry out your plan?" (Guns, pills, etc.)
   5. "Have you rehearsed or practiced the way you would do it?"
   6. "Do you tend to be impulsive?" (Assume "yes" answer to this for all adolescents)
   7. "How strong is your intent to do this?"
   8. "Can you resist the impulse to do this?"
   9. "Have you heard voices telling you to hurt or kill yourself?"
10. Categorize the patient's risk based on responses to questions above
11. Imminent risk of Attempting Suicide:
    1. Patient expressed intent to die, has a plan, and has the means to carry out the plan, especially in presence of despair and hopelessness
    2. Psychotics hear voices telling them to hurt or kill themselves: command hallucinations"
    3. Suicide may be attempted within 48 hours
12. Short-term Risk of Attempting Suicide:
    1. Patient does not exhibit suicidal ideation or behavior but has more than one other significant risk factor
    2. Depression, substance abuse, high anxiety, panic disorder
    3. Previous serious suicide attempts
    4. Family history of suicide
13. Long-term Risk of Attempting Suicide:
    1. Patient has one more risk factors in relatively minor form
    2. Exhibits no suicidal behavior or ideation

C. Management [7]

1. Imminent Risk
   1. Do not leave patient alone in exam room - have someone sit with them
   2. Arrange for psychiatric hospitalization
   3. Have patient transported to the hospital by ambulance or police
2. Short-TermRisk
   1. Commit yourself to helping the patient through the crisis
   2. Present your plan to for helping him or her to the patient
   3. Include increased contact by phone or office visit in the plan
   4. Inform and involve someone close to the patient - spouse, child, friend, parent
3. Ensure that the patient does not have access to the means or opportunities to attempt suicide - consider guns, drugs, ropes, cables, automobiles (carbon monoxide)
4. If substance abuse screen is positive, assess severity of substance abuse problem
5. Refer patient for appropriate treatment - inpatient detoxification, outpatient detoxification, day treatment, 12 Step self- help programs
6. Cognitive therapy reduced suicide attempts from 41% (control) to 24% within 18 months of initial suicide attempt [6]

D. Depression and Suicide

1. If depression screen is positive and substance abuse screen is positive, attempt to gain control over substance abuse problem
2. In many cases depression will resolve after substance abuse problem is under control
3. If depression screen is positive but substance abuse screen is negative, treat depression vigorously
4. Maintain close contact after initiating antidepressant therapy - risk of suicide may increase for a short time after patient begins treatment
5. If patient has history of refractory depression or shows poor response after adequate trial of antidepressant, consider electroconvulsive therapy
6. Be careful about the drugs prescribed - consider overdose potential
7. If anxiety and/or panic disorder are present, consider a stepped approach to therapy
8. Medications
   1. Prescribe a drug with anxiolytic properties but low abuse potential, such as buspirone (Buspar®) or sertraline (Zoloft®), that will not produce immediate relief
   2. Also prescribe a benzodiazepine for short term symptom relief (small number of pills)
   3. Taper the benzodiazepine as the other drug becomes effective
   4. Consier adding an atypical antipsychotic
   5. Avoid tricyclic antidepressants (TCA) and typical antipsychotics until patient is stable
   6. Once patient is stable (not suicidal), TCA and typical antipsychotics may be used
9. Additional Considerations
   1. Supportive psychotherapy
   2. Consider electroconvulsive therapy (ECT)
10. Long-term risk
    1. Attempt to improve all modifiable risk factors
    2. Treat psychiatric disorders
    3. Treat substance abuse disorders
    4. Encourage patient to develop network of supportive relatives and friends
    5. Maintain frequent contact with patient

E. Manage Your Liability Exposure

1. Despite your best efforts, some patients will succeed in killing themselves
2. In this event, express condolences to the family in a neutral fashion that neither accepts nor assigns blame
3. Practitioners who care for suicidal patients and document risk factors for suicide but fail to assess the patient's risk or manage it may be open to malpractice claims in the event of a successful suicide
4. Thoroughly document suicide risk factors, your assessment of the patient's overall suicide risk, plan for treatment and course of events
5. Include familial involvement or lack thereof in documentation

References

1. Maris RW. 2002. Lancet. 360(9329):319
2. Hirschfeld RMA and Russell JM. 1997. NEJM. 337(13):910
3. Muller-Oerlinghausen B, Berghofer A, Bauer M. 2002. Lancet. 359(9302):241
4. Brent DA and Birmaher B. 2002. NEJM. 347(9):667
5. Freedman R. 2003. NEJM. 349(18):1738
6. Brown GK, Have TT, Henriques GR, et al. 2005. JAMA. 294(5):563
7. Mann JJ, Apter A, Bertolote J, et al. 2005. JAMA. 294(16):2064
8. Harris NS. 2006. NEJM. 355(6):602 (Case Record)