• Clinical science

Suicidality

Abstract

Suicide refers to the act of intentionally killing oneself. If that action fails, it is called a suicide attempt. Suicide and suicide attempt can be summed up under the term suicidal behavior. Suicidal behavior requires a mental process that includes both general thoughts about suicide and concrete, deliberate plans to act upon those ideas (suicidal ideation).

While attempted suicide is more common in women, successful suicide is significantly more common in men. Suicidal ideation is almost always a symptom of psychiatric illness (e.g., major depressive disorder). The most important diagnostic step is the evaluation of possible suicidal ideations and prior suicide attempts. Acute management is focused on stabilization and preventing imminent acts of suicide (e.g., by admitting the patient to a psychiatric institution). Thereafter, underlying conditions and risk factors must be addressed (e.g., treatment with antidepressants). Soon and frequent follow-ups are vital to prevent recurrence of suicidal ideation.

Epidemiology

Suicide

  • Incidence:
    • There are ∼ 44.000 suicides every year in the US.
    • Suicide is the 8th leading cause of death in the US overall and the 3rd leading cause in 15–24 year olds.
  • Age:
    • Peak incidence: 45–64 years
    • Incidence significantly increases after age 20 with another significant increase after age 45
  • Sex: >

Suicide attempt

  • Incidence:
  • Age: peak incidence between 15 and 19 years
  • Sex: >

Suicides are more common in men, suicide attempts are more common in women! This is due to the fact that men usually use more lethal methods!

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

The biggest risk factors for suicidal behavior are:

  • Previous suicide attempt(s)
  • Other psychiatric disorders (e.g., major depressive disorder, alcohol or substance abuse, psychotic symptoms, history of aggressive behavior)
  • Other chronic and/or serious diseases (e.g., cancer or chronic pain)
  • Age > 45 years
  • Male sex
  • Possession of firearms
  • Social factors: unemployment, no spouse, poor social support/few social contacts, early loss of a parent

SAD PERSONS - sex (male), age (older than 45), depression, previous suicide attempt, ethanol/substance abuse, rational thinking loss, sick (chronic disease), organized plan (access to weapons/tools), no spouse, social support lacking

References:[1][3][4]

Diagnostics

  • General psychiatric evaluation (e.g., mood disorders, substance abuse, recent severe psychic stress/trauma)
  • Ask specifically and directly about suicidal ideation and concrete intent/plans; to act on such thoughts and evaluate whether the patient is in a position to act on them (e.g., whether the patient possesses a firearm).
  • Ask about previous suicide attempts (also within the family), feelings of despair, and ambivalence towards death.

If there is any reason to suspect suicidal ideation, ask the patient about it!References:[1][4]

Treatment

Acute management

  • Imminent risk of suicidal behavior (suicidal ideation, intent and concrete plan)
    • Immediately reduce the risk, actively prevent the patient from suicidal behavior and assure the patient's safety.
      • Hospitalization (even against the patients will If both clear suicidal ideation and concrete plan/intent are present) )
      • Remove objects from the patient's environment that could be used in a suicide attempt.
      • Do not leave the patient alone or even with his family.
      • If necessary, involve authorities (e.g., local police).
  • Elevated risk of suicidal behavior (suicidal ideation and intent but no concrete plan)
    • Involve the family of the patient and inquire about the patient's psychological and social situation (e.g., history of suicidal ideation, access to firearms, social connections).
    • Take measures to increase the patient's social contacts and interaction with medical professionals.

Long-term management

  • Treat underlying psychiatric disorders.
  • Improve social circumstances that constitute risk factors for suicidal behavior (e.g., change living conditions and increase social contacts).

If antidepressants such as SSRIs are given, the increase in energy and motivation usually occurs sooner than the improvement in mood. Therefore, suicide risk may actually increase during the first weeks of treatment! Close observation and frequent follow-ups are vital!

References:[4][5]

Follow-up

  • After a suicide attempt, the risk for a new attempt can fluctuate depending on several factors (e.g., changing social situation, medications).
  • The risk of suicide is increased in the first weeks following discharge from psychiatric care → soon (ideally within 7 days after discharge) and frequent follow-ups are vital to prevent recurrence of suicidal behavior.

References:[4]

Special patient groups

Patients with depression

  • Severe depression: recovering patients have a higher risk for suicidal behavior than patients who are still depressed.
  • If patients who were previously agitated suddenly become calm, the risk for suicidal behavior increases.
  • The belief to suffer from a serious illness also increases the risk for suicidal behavior.

Minors

If minors are hospitalized due to serious suicidal ideation, their parents must be informed; however, parental (or legal guardians) consent for such action is not required.

References:[3]

  • 1. Le T, Bhushan V, Chen V, King M. First Aid for the USMLE Step 2 CK. McGraw-Hill Education; 2015.
  • 2. American Foundation for Suicide Prevention. Suicide Statistics. https://afsp.org/about-suicide/suicide-statistics/. Updated January 1, 2017. Accessed July 16, 2017.
  • 3. Fadem B. High-Yield Behavioral Science. Alphen aan den Rijn, Netherlands: Wolters Kluwer Health; 2012.
  • 4. Schreiber J, Culpepper L, Roy-Byrne PP, Solomon D. Suicidal Ideation and Behavior in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults. Last updated June 7, 2017. Accessed July 16, 2017.
  • 5. Cipriani A, Pretty H, Hawton K, Geddes JR. Lithium in the prevention of suicidal behavior and all-cause mortality in patients with mood disorders: a systematic review of randomized trials. Am J Psychiatry. 2005; 162(10): pp. 1805–1819. doi: 10.1176/appi.ajp.162.10.1805.
last updated 11/19/2018
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