Suicide
Karen M. Kress, Jill C. Cash, Cheryl A. Glass, and Alyson Wolz
Definition
A.Suicide is defined as the intentional destruction of one’s own life. It is the most critical consequence of mental illness and occurs in all diagnostic psychiatric categories. Knowing the risk factors for suicide and eliciting key clinical features that differentiate the truly suicidal patient from the attentionseeker are of utmost importance. Symptoms are often missed because they can be very subtle. Because there are important legal, social, and religious implications to suicide, the general healthcare practitioner should not attempt to treat these high-risk patients. This section focuses on identifying the suicidal patient for immediate referral to a psychiatrist or psychiatric inpatient facility.
Incidence
A.The Rule of Sevens is helpful in the assessment of these patients:
1.One out of seven with recurrent depressive illness commit suicide.
2.70% of suicides have depressive illness.
3.70% of suicides see their primary care physician within 6 weeks of suicide.
4.Suicide is the 10th leading cause of death in the United States; for young people between the ages of 10 and 34, it is the second leading cause of death and it is the fourth leading cause for ages 35 to 54.
B.The United States averages 10.6 suicides per 100,000 population annually. Every year between 30,000 and 35,000 people take their own lives, not including those individuals who die as a result of fatal accidents due to impaired concentration and attention, and death due to illnesses that may be sequelae (e.g., alcohol abuse).
C.According to the World Health Organization, by the year 2020, depression will be the number two cause, worldwide, of individuals losing healthy years of their lives to depression. Estimates associate 16,000 suicides in the United States annually with depressive disorder. Fifteen percent of those hospitalized for major depressive disorder attempt suicide. Fifteen percent of patients with severe primary major depressive disorder of at least 1 month’s duration eventually commit suicide. Firearm is the most common method of suicide (56.6%) for males and poisoning (33%) and firearm (32.1%) are the most common method of suicide for females.
D.The rate of suicide in young adults has more than doubled since 1950. Little is known about midlife suicides compared to adolescent and elderly suicides. Midlife suicide rates tend to be highest among White men, although female suicide rates peak in midlife. Males exceed females in suicide completions but not in attempts. Whites are twice as likely as non-Whites to commit suicide, though in the 25- to 34-year age group their rates are equal. Rates for widowed, divorced, or separated individuals are higher than for those who are married. Rates are highest in Protestants, intermediate in Jews, and lowest in Catholics.
Pathogenesis
A.Recent studies confirm that some changes in the noradrenergic system along with reduced serotonin levels are associated with suicide. In recent studies independent of psychiatric diagnoses, one researcher identified a suicidality syndrome consisting of hopelessness, ruminative thinking, social withdrawal, and lack of activity as core symptoms.
B.Familial, genetic, early life loss experiences, and comorbid alcoholism may be causal factors. In adolescence, depression is the largest single risk factor for suicidal behavior, although family relationship difficulties make a significant independent contribution to this. Environmental stressors in the presence of psychiatric disorders may also be responsible for initiating the impulsive behavior leading to suicide. The risk of suicidal behaviors is higher in those with mental disorders than in those with mood disorders.
Predisposing Factors (SAD PERSONAS
)
S = sex.
A = age.
D = depression.
P = previous attempts.
E = ethanol abuse.
R = rational thinking loss.
S = social support loss.
O = organized plan.
N = no spouse.
A = availability of lethal means.
S = sickness.
Also consider gender, race and ethnicity, medications, and other medical conditions.
Common Complaints
A.Overt or indirect suicide talk or threats: You won’t be bothered by me much longer.
Any mention of dying or ending one’s life must be taken seriously.
B.Depressed or anxious mood due to depression.
Every depressed patient must be assessed for suicide risk.
C.Significant recent loss such as spouse, job, or self-esteem.
D.Unexpected change in behavior such as making a will, intense talks with friends, and giving away possessions.
E.Unexpected change in attitude such as suddenly cheerful, angry, or withdrawn.
F.Atypical symptoms of depression in the elderly such as impaired ability to communicate, intractable tinnitus, and feelings of helplessness.
Other Signs and Symptoms
Indications for hospitalization of suicidal patients:
A.Psychosis.
B.Intoxication with drugs or alcohol that cannot be evaluated and treated over a period of time in the emergency department.
C.No change in affect or symptoms despite the intervention of the physician, family, and friends.
D.Command hallucinations.
E.Lack of access to, or low availability of, outpatient resources.
F.Family exhaustion.
G.Escalating number of suicide attempts.
H.Uncertainty about the risk of suicide.
I.Severe psychic anxiety, anxious ruminations, and global insomnia are acute risk factors.
Subjective Data
A.Ascertain the patient’s intention. Ask why he or she wants to die:
1.Asking the patient about suicide does not give the patient any ideas about suicide.
B.Determine whether the patient has thought of a suicide plan. The more specific the plan, the more likely the act. A well-worked out, realistic, and potentially lethal plan suggests great risk.
C.Rule out the presence of psychiatric or organic factors such as psychotic depression, thought disorder, or sedative self-medication.
D.Determine whether the precipitating crisis is resolving satisfactorily to the patient.
E.Take an inventory of loss.
Determine the losses the patient has incurred in the last several months or years.
F.Review the patient’s plans for the future.
G.Determine whether the patient thinks he or she is going to commit suicide.
H.Evaluate whether the patient has a caring family or other support systems.
Physical Examination
A.Check pulse, respirations, blood pressure, and weight.
B.Inspect:
1.Observe overall appearance; note grooming, tone of voice, conduct of patient during communication.
2.Complete dermal examination. Check for physical evidence of suicidal behavior such as wrist lacerations or rope burns around the neck. Look for signs of substance use.
C.Palpate:
1.The neck and thyroid; note the goiter.
2.The axilla and groin for lymphadenopathy (infectious etiology).
D.Auscultate:
1.The heart, lungs, and abdomen (as applies to physical complaints).
E.Neurologic examination:
1.Complete mental status review: Specific concern exists when patient displays a flat affect when discussing thoughts or plans for suicide.
2.Assess for thought disorder: Is the patient having command hallucinations telling him or her to harm or kill him- or herself? Is the patient having delusions or a strong sense of burdensomeness,
thinking that others will be better off without him or her?
3.Is the patient exhibiting obsession with taking his or her own life?
Diagnostic Tests
A.Complete blood count (CBC) with differential.
B.Electrolytes, serum calcium, and phosphorus.
C.Thyroid profile.
D.Liver profile.
E.Blood urea nitrogen (BUN), creatinine.
F.Blood alcohol.
G.Urine drug screen.
H.ECG.
I.Rapid plasma reagin (RPR).
J.CT and MRI scans.
K.Perform the Mini-Mental State Examination to rule out dementia/delirium.
L.Perform suicide assessment using an assessment tool such as the Suicide Behavior Questionnaire-Revised (SBQ-R) available at www.integration.samhsa.gov/images/res/SBQ.pdf.
Differential Diagnoses
A.Mood disorder due to another medical condition.
B.Adjustment disorder with depressed mood.
C.Personality disorders.
D.Psychotic disorder.
E.Alcoholism and drug abuse/dependence.
F.Dementia/delirium.
G.Side effect of medication (antidepressants, antipsychotics).
Plan
A.General interventions:
1.If the patient is suicidal, refer immediately. Make sure there is someone with the patient at all times.
2.If the patient came alone, call a family member or friend to accompany the patient to the hospital emergency room or treatment center.
3.If you are fearful the patient will try to escape or leave unaccompanied, escort the patient to the hospital emergency room where commitment papers for involuntary hospital admission can be completed.
Be sure to advise the hospital staff of your concerns regarding the patient’s suicidal status.
B.Patient teaching:
1.Educate patient and family regarding treatment with medication for depression. Discuss benefits/risks of medication and side effects.
2.Encourage the patient to enroll in counseling with a psychologist/therapist to discuss current problems/needs.
3.Determine if social services need to be contacted for patient for support services.
4.Provide local resources for counseling and social services as appropriate.
5.If patient is not hospitalized, make sure that family or friends are aware of the patient’s status and that he or she has someone to talk to and monitor his or her condition until the next office appointment.
C.Pharmaceutical therapy:
1.Patients with suicide potential should never be given more than 1 g or 1 week’s supply of tricyclic antidepressants (TCAs).
2.Documentation is critical. Make sure all statements are recorded and the decision-making process is followed.
3.See this chapter for sections on depression and/or bipolar disorder for complete pharmacological interventions for specific mood disorders.
4.Antidepressants such as selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and antianxiety medications can help to reduce symptoms of depression and severe anxiety, which may help the patient to feel less suicidal.
5.Clozapine is a Food Drug Administration (FDA)- approved medication for reduction of suicidal behavior in patients with schizophrenia.
6.Quetiapine and lithium have been shown to prevent suicide in patients with bipolar depression.
Follow-Up
A.After emergency admission for suicidal ideation or threats, patients should be closely observed, especially in the first year after the serious suicide attempt.
B.With each visit, question the patient regarding suicidal ideation or a plan (see section Subjective Data
for important questions to ask).
Consultation/Referral
A.Consult with the patient’s psychiatric practitioner. Obtain a release of information from the patient.
B.Be sure the patient continues to follow up with psychiatric counseling and medication management (see Depression
section of this chapter).
Individual Considerations
A.Pregnancy:
1.A woman with a history of depression or previous postpartum depression is at high risk for postpartum depression (recurrent; see Postpartum Depression
section in Chapter 16).
B.Geriatrics:
1.White men, age older than 80, have the highest rate of suicide of any age group in the United States.
2.Older persons use the usual means for suicide as well as a slower plan including not eating, stopping prescription drugs or overmedicating, increasing alcohol intake, and refusing treatment.
3.The elderly population is more susceptible to the adverse effects of medications.