Suicide is often an ending to a long process and the consequence of a lifelong accumulation of risk factors, an absence of protecting factors and, finally, the presence of precipitating factors.
In most cases of suicide (over 90%) the person has a previous history of mental health problems, usually mood disorders or substance abuse.
Suicides can be prevented by the assessment of both short-term and long-term suicide risk in those belonging to the risk groups and by enhancing treatment of mental disorders and providing psychosocial support for those at risk of suicide.
The possibility of suicidal ideation and behaviour must always be explored in a depressed patient.
If the patient harbours suicidal thoughts, establish the degree of suicidal intent (plans, timing).
Ensure that the treatment of a suicidal patient is sufficiently protective and do not prescribe large amounts of medicines at any one time.
Self-harm (self-inflicted cuts) and other behaviours suggestive of suicidal intentions are fairly common among adolescents in western countries (5-9%). If this is accompanied with a strong wish to die the person's suicide risk is increased.
About 1-5% of the population has attempted suicide. Attempts are more common among young adults than in older individuals, and more than half of the attempts occur while intoxicated.
The suicide rates among adolescents in relation to all suicides have been on the increase in the 2000's.
Risk factors
Factors which increase long-term suicide risk
Social risk factors (male gender, living alone, low income, unemployed)
Suicide of a close relative or friend (a risk factor particularly among the young)
Mental health problems (mood disorders, substance dependence, unstable and antisocial personality disorder, psychoses)
Serious physical disease, pain
Genetic or familial predisposition
Tendency to impulsive-aggressive behaviour
In men severe mental symptoms in childhood (anxiety, behavioural symptoms)
Immediate or short-term suicide risk
Suicide attempt during the past 12 months
Negative life events: especially divorce/separation, experiences of loss and events leading to strong feelings of shame or guilt; especially in adolescents arguments and disappointments as triggering factors behind self-destructive behaviour Risk of Suicide in Adolescence
Psychological risk factors: hopelessness, negative life expectations, general dissatisfaction with life, impulsivity
Severely symptomatic psychiatric disorder
The risk of suicide is very high around a hospital admission for psychiatric treatment, at the start of the treatment and during the first month after discharge.
Depression
Psychotic depression, feelings of guilt, nihilistic and somatic delusions
Agitation, anxiety, panic attacks
Bipolar disorder
Mixed states
Schizophrenia
Early years of the illness
Frequent hospitalisations, severe form of disease
Uncontrolled substance abuse (young individuals in particular)
Investigation and assessment of self-destructiveness
Suicidal behaviour should be actively discussed and always tackled with the patient.
Suicidality is not a disease, but a mode of behaviour, often associated with psychiatric morbidity. The best understanding can be achieved through viewing the patient's overall psychosocial situation.
It is natural and important to ask about death wishes and self-destructive thoughtswhen assessing the overall situation.
In Finland, of the people who committed suicide in 1987-88, 40-60% had sought medical help during the last month of their life, 18% actually during the last day of their life due to problems associated with their general health, but only very few had communicated any suicidal ideation.
It is worth asking about the thoughts when the patient brings up negative feelings and experiences associated with a physical illness or e.g. pain.
Possible questions
How are you coping with your physical problems? Are you able to carry on?
If indicated, you can proceed question by question: Have you ever thought that your life is not worth living? Would you like to die? Have you ever had suicidal thoughts? Have you contemplated suicide? In what way? What has stopped you from committing suicide? etc.
To elicit more information about self-destructive thoughts, ask specific questions about their content, the possible existence of a plan, timetable.
Questionnaires used to evaluate suicidal ideation and intent:
Assessment and treatment of a patient who has attempted suicide
A physician should assess the need and urgency of the initial somatic and psychiatric treatment of a patient who has attempted suicide.
The background of and reasons for a suicide attempt is clarified with open questions. Always ask whether the patient has any earlier suicide attempts, whether the attempt was associated with a wish to die and what was the lethality of the method used in the attempt. The aforementioned questionnaires can also be used to assist in the investigation of self-destructive behaviour.
The psychiatric evaluation of patient who has attempted suicide must be led by a specialist in psychiatry or by a physician with special expertise in psychiatry. An adolescent who has attempted suicide must always be evaluated within specialized care.
Consult psychiatric specialist services and, based on the consultation, proceed with a referral to emergency care if
the patient exhibits suicidal behaviour (ideation, attempts) associated with a psychiatric disorder
a suicidal patient (ideation, attempts) has no social network to offer support.
Psychiatric hospitalisation is often indicated when a suicidal patient
cannot control his/her self-destructive impulses and shows
psychotic thoughts
impulsive behaviour
intermittent uncontrolled substance abuse
strong self-destructive inclination.
is openly psychotic
is very distressed or agitated or shows severe hopelessness
is covering up or denying the suicide intent (e.g. after a planned suicide attempt).
The patient can be referred to a hospital for observation, with the view of possibly subsequently committing him/her to involuntary psychiatric treatment, if there is suspicion of a mental illness and risk of suicide; for a young person a suspicion of a severe mental disorder is sufficient for a referral.
Family members should be informed of the hospital admission unless explicitly forbidden by the patient.
Electroconvulsive therapy (ECT) or ketamine therapy carried out in hospital has been found to be beneficial in the treatment of acute self-destructive behaviour.
After hospitalization, outpatient care contact for patients who have attempted suicide should be close during the first few months.
Outpatient care alone is considered more beneficial than hospital care for patients with long-term self-destructiveness when suicide attempts have not been severe and the patient has a current functional psychiatric outpatient contact and social support.
If referral for psychiatric care after a self-destruction attempt is not indicated based on sufficient psychiatric evaluation, the patient must be given instructions on whom and how he/she can contact if self-destructive thoughts should become active.
Telephone follow-up may be beneficial after a suicide attempt as part of treatment.
Cognitive behaviour therapy (CBT) as an adjunct to usual care reduces the risk of suicide attempt recurrence.
Various psychotherapeutic methods have been developed for the treatment of patients who are self-destructive or have attempted suicide. There are research publications, particularly in the dialectic and cognitive orientations. Brief therapeutic interventions are also available (e.g. Attempted Suicide Short Intervention Programme, ASSIP http://assip.ch/).
Explore the reasons behind the patient's wish to die (emotional distress, problems with life?) by going through the series of events related to the suicide attempt with him/her. This helps the patient to understand the development of self-destructiveness and to create an individual safety plan for possible further crisis situations.
It is important to relieve the feelings of hopelessness. Emphasise the irreversibility of death and that it is not a solution to problems or feelings of distress.
Relate the suicide ideation with the emotional distress: depression is often accompanied by a feeling of hopelessness and a wish to die, and these will improve as the depressive symptoms are relieved.
Explain how and in what timescale medication, and other treatment modalities, can ease the patient's distress.
Explore factors in the patient's life that can act as protective factors against suicide: including close family members and the effect of the possible suicide on their lives.
Points to consider during treatment
The full therapeutic benefit of antipsychotics and antidepressants is not reached until about a week after the treatment is started. Benzodiazepines relieve anxiety quickly.
When the symptoms of a person suffering from depression are alleviated, also self-destructive thinking decreases and the risk of being self-destructive reduces. Starting antidepressant drug therapy may sometimes increase self-destructive thoughts, and a close follow-up of pharmacotherapy is necessary in the initial phase.
Prescribe only small amounts of medicines at any one time.
Tell the patient how to get in touch and obtain crisis assistance 24 hours a day.
Attempt to find out whether the patient has specific equipment at home necessary for committing suicide (other medication, a weapon etc.)
Identify the patient's social network (a support person) and aim at creating a safety net within health care, as well as an action plan for emergency situations. Involving the family of the self-destructive individual in the evaluation and management improves the prognosis. A safety plan may be developed http://www.kaypahoito.fi/xmedia/hoi/hoi50122b.pdf.
Support the patient's abstinence from substances of abuse, since these predispose to self-destructive behaviour.
An active therapeutic approach that reaches for the patient is needed to make the patient who attempted suicide to commit to treatment. It is important to be in contact with the patient and to allow him/her to take contact even after the active treatment has ended. An agreement can be made with the patient that allows him/her to contact the treating unit without new referral for a period of e.g. 3 months, should his/her condition worsen again.
Suicide prevention (long-term suicide risk)
The most important aspect of prevention is the appropriate treatment of an underlying psychiatric disorder. In as many as 80% of completed suicides, the treatment of the psychiatric disorder has been insufficient.
In follow-up studies lithium used for bipolar disorder and clozapine used for schizophrenia seem to have a decreasing effect on self-destructiveness.
Scientific evidence exists on primary health care education programmes: depression recognition and appropriate treatment by general practitioners reduced local suicide rates during the follow-up period.
References
Mann JJ, Michel CA, Auerbach RP. Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review. Focus (Am Psychiatr Publ) 2023;21(2):182-196 [PubMed]
[Suicide prevention and treatment of a patient who has attempted suicide]. A Current Care Guideline. Working group appointed by The Finnish Medical Society Duodecim, MIELI Mental Health Finland, Finnish Psychiatric Association, Finnish Youth Psychiatric Association and The Finnish Association for General Practice. Helsinki: The Finnish Medical Society Duodecim, 2020 (accessed 7 Jan 2025). Available in Finnish at http://www.kaypahoito.fi/hoi50122.
Temes CM, Frankenburg FR, Fitzmaurice GM, et al. Deaths by Suicide and Other Causes Among Patients With Borderline Personality Disorder and Personality-Disordered Comparison Subjects Over 24 Years of Prospective Follow-Up. J Clin Psychiatry 2019;80 [PubMed]
Gysin-Maillart A, Schwab S, Soravia L, et al. A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP). PLoS Med 2016;13(3):e1001968. [PubMed]
Ribeiro JD, Franklin JC, Fox KR, et al. Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies. Psychol Med 2016;46(2):225-36 [PubMed]
Henriksson MM, Aro HM, Marttunen MJ, et al. Mental disorders and comorbidity in suicide. Am J Psychiatry 1993;150(6):935-40 [PubMed]
Beck AT, Schuyler D, Herman I. Development of suicidal intent scales. In: Beck AT, Resnik HLP, Lettieri DJ (eds.). The prediction of suicide. Philadelphia: Charles Press 1974, p. 45-56.