suicide

Suicidal behavior includes 3 types of self-destructive acts: completed suicide, attempted suicide, and suicide gestures. Thoughts and plans about suicide are referred to as suicide ideation.

Completed suicide is a suicidal act that results in death. Attempted suicide is an act intended to be self-lethal, but one that does not result in death. Frequently, suicide attempts involve at least some ambivalence about wishing to die and may be a cry for help. Suicide gestures are attempts that involve an action with a very low lethal potential (eg, inflicting superficial scratches on the wrist, overdosing on vitamins). Suicide gestures and suicide ideation may reflect pleas for help from people who still wish to live. However, they should not be dismissed lightly (see also the American Psychiatric Association’s Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors).

Epidemiology

Statistics on suicidal behavior are based mainly on death certificates and inquest reports and underestimate the true incidence. Suicide ranks 11th among causes of death in the US, with 32,439 completed suicides in 2004. It is the 3rd leading cause of death among people 10 to 24 yr. Men ≥ 75 have the highest rate of death by suicide. In all age groups, male deaths by suicide outnumber female deaths by 4:1.

Each year, an estimated > 700,000 people attempt suicide. About 25 attempts are made for every death that occurs by suicide. However, 3.5 to 12.5% of people who make an attempt eventually die by suicide because many people make repeated attempts. About 20 to 30% of people who attempt suicide try again within 1 yr. Women attempt suicide twice as often as men, but men complete suicide 4 times more often than women.

People in a secure relationship have a significantly lower suicide rate than single people. Attempted and completed suicide rates are higher among those who live alone. Suicide is less common among practicing members of most religious groups (particularly Roman Catholics).

Group suicides, whether of many people or only 2 (such as lovers or spouses), represent an extreme form of personal identification with others.

A suicide note is left by about 1 in 6 people who complete suicide. The content may indicate the mental disorder that led to the suicidal act.

Etiology

Suicidal behaviors usually result from the interaction of several factors. The primary remediable risk factor in suicide is depression. Suicide and suicide attempts appear to be more common among patients with anxiety disorders, and severe anxiety is associated with major depression or bipolar disorders.

Other factors include the following:

Social factors

Personality abnormalities

Traumatic childhood experiences

Serious physical disorders

Alcohol and drugs of abuse

Serious psychiatric disorders

Certain social factors (eg, disappointment, loss) and personality abnormalities (eg, impulsivity, aggression) appear associated with suicide. Traumatic childhood experiences, particularly the distresses of a broken home, parental deprivation, and abuse, are significantly more common among people who commit suicidal acts. Suicide is sometimes the final act in a course of self-destructive behavior, such as alcoholism, reckless driving, and violent antisocial acts. Often, one factor (commonly disruption of an important relationship) is the last straw. Serious physical disorders, especially those that are chronic and painful, play an important role in about 20% of suicides among the elderly.

Alcohol and drugs of abuse may increase disinhibition and impulsivity, as well as worsen mood, a potentially lethal combination. About 30% of people who attempt suicide have consumed alcohol before the attempt, and about half of them were intoxicated at the time. Alcoholics are suicide-prone even when sober.

Some patients with schizophrenia commit suicide, sometimes because of depression, to which these patients are prone. The suicide method may be bizarre and violent. Attempted suicide is uncommon, although it may be the first sign of psychiatric disturbance, occurring early in schizophrenia.

People with personality disorders are prone to attempted suicide—especially emotionally immature people with a borderline or an antisocial personality disorder because they tolerate frustration poorly and react to stress impetuously with violence and aggression.

Aggression toward others is sometimes evident in suicidal behavior. Rarely, former lovers or estranged spouses are involved in murder-suicides; one person murders the other, then commits suicide.

Methods

Choice of methods is determined by many things, including cultural factors and availability as well as the seriousness of intent. Some methods (eg, jumping from heights) make survival virtually impossible, whereas others (eg, drug ingestion) may allow rescue. However, using a method that proves not to be fatal does not necessarily imply that the intent was less serious.

A bizarre method suggests an underlying psychosis. Drug ingestion is the most common method used in suicide attempts. Violent methods, such as shooting and hanging, are uncommon among attempted suicides. Some methods, such as driving over cliffs, can endanger others. Suicide by police is a bizarre form of suicide; people commit an act (eg, brandishing a weapon) that forces law enforcement agents to kill them.

For completed suicides, firearms are most commonly used by both men (74%) and women (31%), followed by hanging in men and drug ingestion in women.

Management of Suicidal Acts

A health care practitioner who foresees the likelihood of suicide in a patient is, in most jurisdictions, required to inform an empowered agency to intervene. Failure to do so can result in criminal and civil actions. Such patients should not be left alone until they are in a secure environment. They should be transported to a secure environment (often a psychiatric facility) by trained professionals (eg, ambulance, police), never by family members or friends.

Any suicidal act, regardless of whether it is a gesture or an attempt, must be taken seriously. Every person with a serious self-injury should be evaluated and treated for the physical injury. If an overdose of a potentially lethal drug is confirmed, immediate steps are taken to prevent absorption and expedite excretion, administer any available antidote, and provide supportive treatment (see Poisoning).

Initial assessment can be done by any health care practitioner trained in the assessment and management of suicidal behavior. However, all patients require psychiatric assessment as soon as possible. A decision must be made as to whether patients need to be admitted and whether involuntary commitment or restraint is necessary. Patients with a psychotic disorder, delirium, or epilepsy and some with severe depression and an unresolved crisis should be admitted to a psychiatric unit.

After a suicide attempt, the patient may deny any problems because the severe depression that led to the suicidal act may be followed by a short-lived mood elevation. Nonetheless, the risk of later, completed suicide is high unless the patient’s problems are resolved.

Psychiatric assessment identifies some of the problems that contributed to the attempt and helps the physician plan appropriate treatment. It consists of the following:

Establishing rapport

Understanding the suicide attempt, its background, the events preceding it, and the circumstances in which it occurred

Appreciating the current difficulties and problems

Thoroughly understanding personal and family relationships, which are often pertinent to the suicide attempt

Fully assessing the patient’s mental state, with particular emphasis on recognizing depression, anxiety, agitation, panic attacks, severe insomnia, other mental disorders, and alcohol or drug abuse (many of these problems require specific treatment in addition to crisis intervention)

Interviewing close family members and friends

Contacting the family physician

Prevention

Prevention requires identifying at-risk people and initiating appropriate interventions (see Table 1: Suicidal Behavior: Risk Factors and Warning Signs for Suicide).
Table 1

Risk Factors and Warning Signs for Suicide

Type
Specific Factors

Demographic data
Male

Age > 65

Social situation
Personally significant anniversaries

Unemployment or financial difficulties, particularly if causing a drastic fall in economic status

Recent separation, divorce, or widowhood

Social isolation with real or imagined unsympathetic attitude of relatives or friends

History of suicidality
Previous suicide attempt

Making detailed suicide plans, taking steps to implement plan (obtaining gun, pills), taking precautions against being discovered

Family history of suicide or of affective disorder

Clinical features
Depressive illness, especially at onset

Marked motor agitation, restlessness, and anxiety with severe insomnia

Marked feelings of guilt, inadequacy, and hopelessness; self-denigration; nihilistic delusion

Delusion or near-delusional conviction of a physical disorder (eg, cancer, a heart disorder, sexually transmitted disease)

Command hallucinations

Impulsive, hostile personality

A chronic, painful, or disabling physical disorder, especially in formerly healthy patients

Drug use
Alcohol or drug abuse, especially of recent onset

Use of drugs that may contribute to suicidal behavior (eg, abruptly stopping paroxetine

and
certain other antidepressants can result in increased depression and anxiety, which in turn increases risk of suicidal behavior)

Although some attempted or completed suicides are a surprise and shock, even to close relatives and associates, clear warnings may have been given to family members, friends, or health care practitioners. Warnings are often explicit, as when patients actually discuss plans or suddenly write or change a will. However, warnings can be more subtle, as when patients make comments about having nothing to live for or being better off if dead.

On average, primary care physicians encounter ≥ 6 potentially suicidal people in their practice each year. About 77% of people who commit suicide were seen by a physician within 1 yr before killing themselves, and about 32% had been under the care of a mental health care practitioner during the preceding year. Because severe and painful physical disorders, substance abuse, and mental disorders (particularly depression) are often a factor in suicide, recognizing these possible factors and initiating appropriate treatment are important contributions a physician can make to suicide prevention.

Each depressed patient should be questioned about thoughts of suicide. The fear that such inquiry may implant the idea of self-destruction is baseless. Inquiry helps the physician obtain a clearer picture of the depth of the depression, encourages constructive discussion, and conveys the physician’s awareness of the patient’s deep despair and hopelessness.

Even people threatening imminent suicide (eg, those who call and declare that they are going to take a lethal dose of a drug or who threaten to jump from a high height) may have some desire to live. The physician or another person to whom they appeal for help must support the desire to live. Emergency psychiatric aid for suicidal people includes the following:

Establishing a relationship and open communication with them

Reminding them of their identity (ie, using their name repeatedly)

Helping sort out the problem that has caused the crisis

Offering constructive help with the problem

Encouraging them to take positive action

Reminding them that family and friends care for them and want to help

Treatment of depression and risk of suicide: People with depression have a significant risk of suicide and should be carefully monitored for suicidality (suicidal behaviors and ideation). Risk of suicide may be increased early in the treatment of depression, when psychomotor retardation and indecisiveness have been ameliorated but the depressed mood is only partially lifted. When antidepressants are started or when doses are increased, a few patients experience agitation, anxiety, and increasing depression, which may increase suicidality. Recent public health warnings about the possible association between antidepressant use and suicidality in children, adolescents, and young adults have led to a significant reduction (> 20%) in antidepressant prescriptions to these populations. However, youth suicide rates increased by 14% during this period. Thus, by discouraging drug treatment of depression, these warnings may have resulted in more, not fewer, deaths by suicide. Together, these findings suggest that the best approach is to encourage treatment, but with appropriate precautions (dispensing antidepressants in sublethal amounts, giving a clear warning to patients and to family members and significant others to be alert for worsening symptoms or suicidal ideation, and, if either occurs, immediately calling the prescribing clinician or seek care elsewhere).

Effect of Suicide

Any suicidal act has a marked emotional effect on all involved. The physician, family members, and friends may feel guilt, shame, and remorse at not having prevented a suicide, as well as anger toward the deceased or others. The physician can provide valuable assistance to the deceased’s family members and friends in dealing with their feelings of guilt and sorrow.

Assisted Suicide

Assisted suicide refers to the assistance given by physicians or other practitioners to people who wish to end their life. Assistance may be requests about drugs that can be saved up to provide a lethal dose, about instructions for a painless way to commit suicide, or for administration of a lethal dose of drug.

Assisted suicide is controversial and is illegal in most states in the US. Nonetheless, patients with painful, debilitating, and untreatable conditions may initiate a discussion about it

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