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Suicide

BASICS

  • Description:
  • Suicide and attempted suicide are major causes of morbidity and mortality.

EPIDEMIOLOGY

  • Attempted suicide: Women 1.5x > men
  • Completed suicide: Men 3x > women
  • US Data:
  • 10–14, 25–34 yrs: high risk groups (2nd leading cause in 25–34 yrs)

  • 49,000 US deaths in 2022

  • 11th leading cause of death overall (CDC 2021)
  • Highest increases: American Indian/Alaska Native youth (42.6/100,000, +17% from 2020–21), and youth 10–24 yrs, especially gender nonconforming
  • Global Data:
  • 4th leading cause of death in ages 15–29
  • 15th overall (WHO 2020)

RISK FACTORS

  • Previous suicide attempt (80% of completions)
  • Psychiatric diagnosis (90%: depression, bipolar, anorexia, panic, personality disorder, schizophrenia/psychosis)
  • Substance use/withdrawal
  • Family history
  • Physical illness, head injury
  • Teens: lack of connection, bullying, gender identity issues, poor grades
  • Veterans: childhood abuse, major depression, multiple psych admissions
  • Access to lethal means (firearms, poisons, prescription/OTC drugs, pesticides)

GENERAL PREVENTION

  • Educate about 24/7 resources (e.g., 988 Lifeline)
  • Screen for risk using clinical tools (PHQ-2, PHQ-9, Columbia Suicide Severity Rating Scale, Beck Scale for Suicide Ideation, Linehan Reasons for Living, Motto Risk Estimator)
  • Treat underlying mental, medical, substance use disorders
  • Maintain continuity of care (key protective factor, e.g., "Perfect Depression Care" initiative reduced suicide rate 77%)
  • Screen for possession of lethal means
  • Create safety plan for at-risk patients and families
  • Educate public on emergency access and response
  • Specific resources:
  • Military: Real Warriors, "Power of 1" initiative
  • Anyone: 988lifeline.org (call/text 988)
  • Youth: StopBullying.gov, 988lifeline.org/youth
  • Minority communities: 988lifeline.org/black-mental-health/, 988lifeline.org/native-americans/
  • Providers: SPRC

DIAGNOSIS

HISTORY

  • Ask about suicidal ideation and plans:
  • "Have you ever felt life isn't worth living?"
  • "Do you wish you could sleep and not wake up?"
  • "Are you having thoughts of killing yourself?"
  • Use mental-state exam; assess for loss, stress, lack of resources/support
  • Review previous attempts (intent, lethality, rescue precautions, reaction to survival)
  • Review psychiatric/substance history, and reasons to live/social supports
  • Collateral info (friends, family); break confidentiality if imminent risk

PHYSICAL EXAM

  • Assess for chronic/acute illnesses, delirium, intoxication, withdrawal
  • Look for psychosis, agitation, or impaired judgment
  • In teens, screen for adverse childhood experiences, minority status, bullying, isolation, substance use

DIFFERENTIAL DIAGNOSIS

  • Suicidal gestures/threats vs. manipulation (e.g., personality disorder)
  • Must triage for safety regardless of context

DIAGNOSTIC TESTS

TREATMENT

GENERAL MEASURES

  • Immediate psychiatric evaluation for active ideation or attempt
  • Cognitive therapy: reduces reattempts by 50%
  • Psychotherapy: countertransference awareness in clinicians is critical
  • Military: ACE (Ask, Care, Escort) campaign for suicide prevention

MEDICATION

  • Psychopharmacology should not replace clinical assessment
  • Monitor closely at antidepressant initiation or dose changes (especially peds: FDA black box)
  • Treat anxiety, agitation, delusions aggressively if present
  • Sedation (benzos, antipsychotics) for acutely agitated patients in ED/inpatient settings

ISSUES FOR REFERRAL

  • Consider psychiatric consultation in all cases
  • Document & communicate all decisions and care plans

ADMISSION/INPATIENT CARE

  • Hospitalize if active plan or high risk (involuntary if needed)
  • After attempt, treat medical issues first, then psychiatric care
  • Labs: solvent/toxicology screen, acetaminophen, aspirin levels—patients may not reveal all ingestions
  • High risk continues as inpatient—search for contraband, one-to-one observation, offer medication, use restraints if absolutely necessary
  • Risk highest after transfer or post-discharge—monitor closely
  • Discharge when no longer a danger; look for improved mood, engagement, sleep, appetite

ONGOING CARE

FOLLOW-UP

  • Increase monitoring early in treatment, at med changes, and after discharge
  • Educate family/contacts on warning signs
  • Confirm patient accepts follow-up
  • Curtail access to firearms and restrict pill supplies for impulsive patients

PATIENT EDUCATION

  • In acute danger: Call 911, go to ER, contact therapist, call 988 Suicide Prevention Hotline
  • Military/veterans: 1-800-796-9699, 1-800-273-TALK (8255), text: 838255

PROGNOSIS

  • Favorable with early risk recognition, prompt and ongoing treatment

COMPLICATIONS

  • Significant others may suffer guilt, shame, and impaired mourning—recommend counseling/support for survivors

REFERENCES

  1. González-Rodríguez A, Molina-Andreu O, Odriozola VN, et al. Psychiatry J. 2014;2014:834901.
  2. Koola MM, Ahmed AO, Sebastian J, et al. Prim Care Companion CNS Disord. 2018;20(4):18m02317.
  3. Brown GK, Ten Have T, Henriques GR, et al. JAMA. 2005;294(5):563-570.
  4. Ghahramanlou-Holloway M, Neely LL, Tucker J. Curr Psychiatr. 2014;13(8):18-28.

ICD-10 CODES

  • R45.851: Suicidal ideations
  • T14.91: Suicide attempt
  • Z91.5: Personal history of self-harm

CLINICAL PEARLS

  • Key prevention: Listen to patients and take concrete steps for safety, including immediate hospitalization if necessary
  • Family and contacts of suicide victims need support—recommend counseling
  • Resources:
  • AAS
  • SuicideAssessment.com
  • See resources in General Prevention section