Suicide Risk
- category: Mental Health Problems
I. Background
Suicide is ranked as the 11th leading cause of death in the general US population and the 3rd leading cause of death for adolescents and young adults from age 15 to 24 years (1). Although the risk of suicide can be difficult to assess and predict because of the number of factors that contribute to such a decision, an understanding of the risk factors and assessment questions may prevent this tragic event. Many patients visit their primary care provider (PCP) some months before attempting suicide (2). If the red flags of suicidal ideation are present and recognized by the PCP, an opportunity is created for positive intervention to prevent suicide attempts.
II. Pathophysiology
A. Etiology
Suicide is a topic that receives much attention through media and other platforms of discussion -- perhaps because suicide is often viewed as a moral decision that is contrary to many religious and societal values. However, for many individuals who attempt or commit suicide, their quality of life (physical, emotional, and/or spiritual) has become so depleted that they may see no other options. Many factors contribute to a low level of quality of life and, therefore, the decision to take one's own life. Both physical and psychiatric disorders are recognized as being among these factors. Physical contributors include chronic illness and changes in neurotransmitters (i.e., serotonin)(1). Psychiatric disorders include major depression, substance abuse, schizophrenia, panic disorder, and borderline personality disorder (3). Other factors include a history of suicide attempts by the individual or close relatives and friends, violence at home, history of physical or sexual abuse, ownership of a firearm, history of family mental illness, a recent crisis (i.e., loss of income, divorce), illness, and old age. In addition, hopelessness, hostility, negative self-esteem, and isolation have been identified as suicide risk factors in adolescents (4).
B. Epidemiology
The most current data on suicide rates posted by the National Institute of Mental Health (NIMH) from 2001 show that 30,622 individuals died by suicide in the United States that year. To put this in perspective, this is higher than the number of individuals who died by homicide by a ratio of three to two and twice as many as those who died from complications from human immunodeficiency virus/acquired immunodeficiency syndrome. The highest risk population for committing suicide is white men age 85 and over (54 deaths by suicide per 100,000), which is five times greater than the general population (10.7/100,000). Among children, adolescents, and young adults, the latter are at slightly greater risk of committing suicide (12/100,000) than the national average. Among all age-groups, men are more likely to commit suicide than are women (4:1), but women are reported to have made more suicide attempts. White men are most likely to commit suicide, accounting for 73% of all deaths by suicide. Firearms are the most common mode of suicide by both men and women (1).
III. Evaluation
One of the best precautions a PCP can take to assess for suicidal risk is completing a brief history with patients, asking about the previously mentioned risk factors. Although it is not necessary to exhaustively interview all patients, everyone who has any suicide risk factors should be queried about these issues.
A. History
Patients rarely talk to their PCPs about suicidal thoughts or past attempts. In fact, patients rarely bring up issues that may reveal risk factors for suicide (e.g., depression) without being asked directly. Instead, they often discuss the physical manifestations such as headaches, muscle pain, and insomnia. To assess for suicidal ideation, the PCP must ask patients specific questions to uncover their intentions. Patients at greater risk for suicidal ideation or attempts should be assessed for current thought of harming themselves. This can be done easily as part of an assessment for depression such as the Patient Health Questionnaire-9 (PHQ-9)(5) or by simply asking the patients if they are experiencing thoughts of harming themselves. Some PCPs may feel hesitant to ask such a direct question pertaining to suicide for fear that they may be planting an idea in a patient who is already struggling. However, no research has suggested that a patient may kill himself or herself simply because of being asked about thoughts of suicide. On the contrary, at-risk patients must be asked about suicidal thoughts and behavior so that appropriate measures can be taken.
B. Assessment
- If patients have thoughts of suicide and a plan for the same, the PCP should determine how serious the individual is about carrying out the plans of suicide and the time frame for the suicide attempt. Level of seriousness in carrying out suicide plans can be assessed by asking patients if they have told other individuals of the plan to commit suicide and the details of the plan and by asking patients directly how serious they are about actually harming themselves. Also, the PCP should distinguish between a realistic and unrealistic plan to commit suicide. A realistic plan refers to a plan where the individual has the access and means to complete a suicide such as a patient who threatens to overdose on a medication that may have been prescribed. An unrealistic plan refers to a plan that is based on unlikely or impossible means of fulfilling suicidal desires. For example, a patient may state that he wants to shoot himself but does not own a gun, does not know someone who owns a gun, cannot purchase a gun, and does not consider other more realistic means of suicide to which he has access. Although this patient merits concern and in need of a suicide management plan, he may be in less immediate danger than the patient who has developed a realistic and accessible means to end his life. Determining if the plan is realistic or not gives insight into how likely the individual is to commit suicide.
- To determine the suicide attempt time frame, patients should be asked when they plan to attempt suicide and estimate how likely they are to attempt suicide before the next visit to the physician. The answer to these questions should carry weight in determining the level of management. For example, a patient may be very depressed, state a realistic plan of suicide, and offer little reason to live but then say that he will not attempt until his three-year-old child has graduated from high school. Although this individual should receive help, he may not be in immediate danger for suicide.
C. Risk
On the basis of your assessment, a patient's level of risk is determined. For example, a patient who reports that she has had thoughts that she would be better off dead, or even of actually harming herself, but says she has never nor will ever attempt suicide due to personal and religious beliefs and because of family commitments, is different from the patient who reports that he owns firearms, has attempted suicide in the past, and can give no reason for living. Patients may be classified as being in minimal, moderate, or severe risk, and the treatment should be in direct relationship to how the patient is classified.
- The minimal risk category includes patients who have experienced thoughts of self harm but have no specific plan, no history of past attempts, and who state that they would not actually attempt suicide. These are patients who can offer reasons to continue living or at least are active with the PCP in developing a safety plan.
- Moderate risk patients include individuals who have considered a suicide plan (which may or may not be realistic), but say that they do not think they could actually harm themselves. Moderate risk patients may have made attempts in the distant past but are willing to create a safety plan and explore reasons to live.
- Severe risk patients have a specific plan that is realistic and state that they will attempt suicide or will not commit to a no - suicide contract, even for a short duration. These individuals may or may not have a history of past attempts but are at greater risk if they have attempted in the past.
IV. Diagnosis
If a patient responds that they are considering suicide, the suicide assessment becomes the primary focus of the medical appointment. A full assessment and creating a safety plan or admission to the hospital may take as little as ten minutes, or it may take more, depending on staff training and treatment accessibility.
References
1. National Institute of Mental Health. In harm's way: suicide in America. Revised ed. [Brochure]. Bethesda, MD: US Department of Health and Human Services, 2003.
2. Murphy GE. The physician's responsibility for suicide. I. An error of commission. Ann Intern Med 1975;82:301 - 304.
3. Gliatto MF, Rai AK. Evaluation and treatment of patients with suicidal ideation. Am Fam Physician 1999;59:1500 - 1506.
4. Rutter PA, Behrendt AE. Adolescent suicide risk: four psychological factors. Adolescence 2004;39:295 - 302.
5. The MacArthur Initiative on Depression and Primary Care. Tool Kit, at: http://www.depression-primarycare.org, accessed on July 25, 2005.