Practice Essentials

Suicide ranks as the 10th leading cause of death in the United States. Globally, an estimated
700,000 people take their own lives annually.[1] In certain populations, such as adolescents and
young adults, suicide constitutes 1 of the top 3 causes of death. According to the CDC, there were
42,773 suicides in the United States in 2014. [2]
In the United States, certain states have higher suicide rates than others, as illustrated by the map
below.

Suicide
rates in the United States by region, 2000-2006. Courtesy of the US National Institute of Mental Health and
Centers for Disease Control and Prevention.

Suicide-related activities and characteristics

Numerous activities are associated with suicidal potential, including the following:

Making a will
Getting the house and affairs together
Unexpectedly visiting friends and family members
Purchasing a gun, hose, or rope
Writing a suicide note
Visiting a primary care physician - A significant number of people see their primary care
physician within 3 weeks before they commit suicide
Suicidal individuals have a number of characteristics, including the following:
A preoccupation with death
A sense of isolation and withdrawal
Few friends or family members
An emotional distance from others
Distraction and lack of humor - They often seem to be "in their own world" and lack a
sense of humor (anhedonia)
Focus on the past - They dwell on past losses and defeats and anticipate no future; they
voice the notion that others and the world would be better off without them
Haunted and dominated by hopelessness and helplessness

Assessment of suicide risk

A clear and complete evaluation and clinical interview with regard to the following are used to
determine the need for suicide intervention:

Suicidal ideation - Determine whether the person has any thoughts of hurting himself or
herself

Suicide plans - If suicidal ideation is present, the next question must be about any plans
for suicidal acts; the general formula is that more specific plans indicate greater danger

Purpose of suicide - Determine what the patient believes his or her suicide would achieve;
this suggests how seriously the person has been considering suicide and the reason for death

Potential for homicide - Any question of suicide also must be coupled with an inquiry into
the person's potential for homicide
Signs and risk factors
The following is a list of 13 things that should alert a clinician to a real suicide potential:

Patients with definite plans to kill themselves - People who think or talk about suicide are
at risk; however, a patient who has a plan (eg, to get a gun and buy bullets) has made a clear
statement regarding risk of suicide
Patients who have pursued a systematic pattern of behavior in which they engage in
activities that indicate they are leaving life - This includes saying goodbye to friends, making a
will, writing a suicide note, and developing a funeral plan
Patients with a strong family history of suicide - A family history of suicide is especially
indicative of suicide risk if the patient is approaching the anniversary of a family members
suicide or the age at which a relative committed suicide
The presence of a gun, especially a handgun
Psychotic symptoms especially in adolescents - Kelleher et al reported in a prospective
cohort study of 1112 school-based adolescents (aged 13-16 y), that 7% of the total sample
reported psychotic symptoms at baseline. Of that subsample, 7% reported a suicide attempt by
the 3-month follow-up compared with 1% of the rest of the sample. The authors concluded that
adolescents with psychopathology who report psychotic symptoms are at clinical high risk for
suicide attempts. Psychotic symptoms in adolescents may serve as a marked for that population
being at high suicidal risk. [3]
Being under the influence of alcohol or other mind-altering drugs - Drug abuse is
especially significant if the drugs are depressants
If the patient encounters a severe, immediate, unexpected loss, such as when a person is
fired suddenly or left by a spouse
If the patient is isolated and alone
If the person has a depression of any type
If the patient experiences command hallucination - A command hallucination ordering
suicide can be a powerful message of action leading to death
Discharge from psychiatric hospitals - Patients are at suicide risk upon discharge from a
psychiatric hospital, which is a very difficult time of transition and stress; the structure, support,
and safety of the institution are no longer available to the patient
Anxiety - Anxiety in all of its forms leads to a risk of suicide; the constant sense of dread
and tension proves unbearable for some
Clinician's feelings - Regardless of what the patient says or does, it matters if the clinician
has a feeling that the patient is going to commit suicide
Mental status review
Looking at the following patient characteristics, the mental status review is designed to focus on
evaluating an individual's potential for committing suicide:

Appearance - In addition to noting the dress and hygiene of patients who are depressed
(eg, disheveled, unkempt and unclean clothing), the clinician should assess these individuals for
physical evidence of suicidal behavior, such as wrist lacerations and neck rope burns
Affect - One specific concern is a flat affect by the patient when describing his or her
thoughts and plans of suicide and self-destructive behavior
Thoughts - Three types of thought changes represent areas for major focus and concern:
(1) command hallucinations (usually auditory) telling the patient to kill himself or herself, (2)
delusions about the benefits of suicide (eg, family will be better off), (3) an obsession with taking
his or her own life
Homicidal potential
Judgment, insight, and intellect

Orientation and memory - The focus of this part of the mental status review is to
determine if the person is delirious or has dementia

Intervention
Intervention for a suicidal patient should consist of multiple steps, as follows:

The individual must not be left alone

Anything that the patient may use to hurt or kill himself or herself must be removed
The suicidal patient should be treated initially in a secure, safe, and highly supervised
place; inpatient care at a hospital offers one of the best settings
After the initial intervention, which usually includes hospitalization, it is critical that there be in place
an ongoing management treatment plan.

Pharmacologic therapy
Treatment of a patients underlying psychiatric illness consistently appears to be the most effective
use of pharmacologic therapy in suicidal persons.

Image library

Suicide
rates in the United States by region, 2000-2006. Courtesy of the US National Institute of Mental Health and
Centers for Disease Control and Prevention.

Overview
Suicide ranks as the tenth leading cause of death in the United States (see the chart below).
[4]
Globally, an estimated 700,000 people take their own lives annually.[1] In certain populations, such
as adolescents and young adults, suicide constitutes 1 of the top 3 causes of death. According to
the CDC, there were 42,773 suicides in the United States in 2014. [2]
An alarming increase in suicides have been reported in the last decade. Rockett et al have
reported that over the past decade, mortality rates for suicide, poisoning, and falls have
substantially increased. Because of traffic safety measures, suicide has surpassed motor vehicle
crashes as the leading cause of injury mortality.[5] This phenomenon is even more compelling
because, in many instances, suicides can be prevented. Therefore, clinicians must recognize the
risk factors for suicide as a way of intervening in a self-destructive event and cycle. See the image
below.

Suicide
rates in the United States by region, 2000-2006. Courtesy of the US National Institute of Mental Health and
Centers for Disease Control and Prevention.

This article discusses the following:

Basic terminology applied to self-destructive activities and events

Risk factors that can alert the clinician to early warning signs of suicide
Interventions if a person's attempt at suicide is imminent
The diagnosis and treatment of the underlying mental disorder causing the self-destructive
behavior

Appropriate actions for a clinician if a person being treated does commit suicide
Depression, isolation, previous suicide attempts, substance abuse, and serious mental illness rank
as highly significant contributors to suicide. Swift and decisive interventions based on a thorough
assessment can save lives. Preventing a person from committing suicide, however, is only the first
step in the treatment of the suicidal patient.

Diagnostic and treatment considerations

Once it has been assured that the patient is safe, the reasons for the individuals self-destructive
behavior must be found. The diagnosis requires a complete psychiatric history and mental status
examination. (See the chart below.)

Sentinel event (SE) suicides by diagnosis and

method. Courtesy of the New York State Office of Mental Health.

The choice of treatment is dictated by the specific mental illness affecting the patient. Talking
therapies can help, and in many instances, medication can alleviate symptoms of mental illness.
Finally, however, despite intervention, if the patient does commit suicide, a number of steps can
and should be undertaken for the patient's family, other patients, the staff, and the therapist.

Terminology
Suicide means killing oneself. The act constitutes a person willingly, perhaps ambivalently, taking
his or her own life. Several forms of suicidal behavior fall within the self-destructive spectrum.
A completed suicide means the person has died. It is important not to use the term successful
suicide; the goal is to prevent suicide and provide treatment.
A suicide attempt involves a serious act, such as taking a fatal amount of medication and someone
intervening accidentally. Without the accidental discovery, the individual would be dead.
A suicide gesture denotes a person undertaking an unusual, but not fatal, behavior as a cry for
help or to get attention.
A suicide gamble is one in which patients gamble their lives that they will be found in time and that
the discoverer will save them. For example, an individual ingests a fatal amount of drugs with the
belief that family members will be home before death occurs.
A suicide equivalent involves a situation in which the person does not attempt suicide. Instead, he
or she uses behavior to get some of the reactions that suicide would have caused. For example,
an adolescent boy runs away from home, wanting to see how his parents respond. (Do they care?
Are they sorry for the way that they have been treating him?) The action can be seen as an
indirect cry for help.

Etiology
A number of factors correlate with serious suicide attempts and completed suicides, including, but
not limited to, the following:

Medications
Mental illness
Sex
Genetics
Availability of firearms
Life experiences
Physical illness
Economic instability and status
Media and the Internet
Psychodynamic formulation
An understanding of the causes of suicidal behavior will not only clarify the roots of the patients
self-destructive path but also help the clinician to determine the appropriate treatment for the
patient. Once the patient is safe, then the underlying dynamics can be addressed.

Medications
A number of medications have been linked to suicidal behavior, which has prompted the US Food
and Drug Administration (FDA) to require a warning on certain prescription drugs, including
antidepressants, anticonvulsants, and analgesics.
Antidepressants
Initially, the FDA and studies linked antidepressants to childhood and adolescent self-destructive
events and required a warning for those populations; however, Schneeweiss and colleagues found
the same linkage for adults as well.[6]
The investigators reviewed data from all 287,543 residents of Canada's British Columbia, 18 years
or older, who had been placed on an antidepressant between 1997 and 2005 and concluded the
following: "Our finding of equal event rates across antidepressant agents supports the US Food
and Drug Administration's decision to treat all antidepressants alike in their advisory. Treatment
decisions should be based on efficacy, and clinicians should be vigilant in monitoring after initiating
therapy with any antidepressant agent."[6]
Anticonvulsants
In 2008, the FDA required a suicidal behavior warning be placed on anticonvulsants. In a 2010
exploratory analysis, Patorno and colleagues suggested that the use of gabapentin, lamotrigine,
oxcarbazepine, and tiagabine, compared with the use of topiramate, may be associated with an
increased risk of suicidal acts or violent deaths. [7]
Pain medication
Tramadol is a narcoticlike pain reliever that, on May 26, 2010, received an FDA addition of a
suicide risk warning (tramadol hydrochloride [Ultram] and tramadol hydrochloride/acetaminophen
[Ultracet]).[8] The FDA noted linkage between tramadol prescriptions and patients with emotional
instability and suicidal ideation and increased self-destructive behavior.[8]
Smoking cessation medications
Moore et al determined that the risk of depression and suicidal or self-injurious behaviors is
substantially increased and statistically significant with the use of varenicline. Risk was also
present, but smaller, with bupropion, and was even smaller with nicotine replacement. The
investigators suggested that varenicline is unsuitable as a first-line agent to aid in smoking
cessation.[9]
Glucocorticoids
A study by Fardet et al concluded that glucocorticoids increase the risk of suicidal behavior and
neuropsychiatric disorders. The authors reviewed data from all adult patients in UK general
practices from 1990 to 2008. Of 786,868 courses of oral glucocorticoids prescribed for 372,696

patients, there were 109 incident cases of suicide or suicide attempt and 10,220 incident cases of
severe neuropsychiatric disorders.[10]

Mental illness
Although mental illness is generally linked to premature deaths, certain mental illnesses carry with
them remarkably high lifetime instances of suicide. In fact, 95% of people who commit suicide
have a mental illness. In a general sense, mental illness all too often is an isolating experience,
with such isolation correlating with suicide.
Hospitalization for a psychiatric disorder is quite prevalent in the suicidal population, [11] including for
people with any depressive disorder, bipolar disorder, schizophrenia, posttraumatic stress disorder
(PTSD), phobias, substance abuse problems, delirium, and dementia, as well as certain genetic
factors.
Each psychiatric disorder has its own distinctive mental status footprint. A mental status review is
designed to help evaluate a persons suicide potential.
The following list represents some of the mental disorders frequently associated with suicidal
behavior, but self-destructive thoughts and acts also may occur in other diagnoses:

Alcoholism
Anxiety disorders
Bipolar affective disorder
Bulimia nervosa
Cocaine-related psychiatric disorders
Delirium
Depression
Dysthymic disorder
Hallucinogens
Obsessive-compulsive disorder
Opioid abuse
Pediatric depression
Personality disorders
Postpartum depression
PTSD
Schizophrenia
Seasonal affective disorder
Social phobia
Vascular dementia
Depression
Because depression involves a preoccupation with death, the twin killers of hopelessness and
helplessness, and withdrawal, it is a major contributor to suicide. A dangerous time in depression
occurs when a patient is coming out of the deepest part of the experience. At that point, the
individual may mobilize his or her newly acquired energy to commit suicide.
The protracted and profound emotional roller coaster of manic-depressive illness puts a patient at
risk both during the depressive phase and in the psychosis of mania. Suicide is a particular risk
when executive functions and judgment have been compromised by bipolar disorder.[12] In
particular, men with bipolar disorder have an increased risk for suicide. [13]
One important consideration in the treatment of depression is that selective serotonin reuptake
inhibitors (SSRIs) have a lower rate of fatal overdoses than do tricyclic antidepressants (TCAs). [14]
Shah et al found that in adults younger than 40 years, depression and history of attempted suicide
are significant independent predictors of premature cardiovascular disease and ischemic heart
disease in males and females.[15]
Bipolar disorder
Patients with bipolar disorder are at risk for suicidal behavior, especially those with an early onset
of symptoms. Goldstein and associates followed the mental health of 413 youths diagnosed with

bipolar disorders and found that 76 (18%) attempted suicide at least once within 5 years of study,
of these, 31 (8% of the overall group and 41% of those who attempted suicide) made many
attempts. They concluded that bipolar disorder with early onset is associated with high suicide
rates. The severity of depression and family history must be considered in assessment of
individuals with bipolar disorder.[16]
Schizophrenia
Schizophrenic patients are at a significantly high risk for suicide. They may experience
hallucinations, often auditory, such as voices commanding them to kill themselves (command
hallucinations). In addition, these individuals may, in the context and as a result of their illness,
become depressed; they realize that they are different from others.
Persons with schizophrenia may also have moments of insight during which they realize that they
may not achieve some life goals that others can accomplish. Individuals who are considered highly
functional seem to be at high risk for suicide, perhaps because of their ability to appreciate how
they are different from others and how their life is different from what they wish it to be.
Finally, the suspicions and fears associated with schizophrenia may promote isolation and
withdrawal.
The high rate of suicide in patients with schizophrenia is higher when physical comorbidity or
substance abuse is also present.[17]
Anxiety disorders and OCD
Obsessive-compulsive disorder (OCD) and phobic disorders have symptoms that make suicide a
possibility. Persons struggling with these symptoms feel frightened, terrorized, isolated, and
physically paralyzed by feelings of anxiety, panic, and dread that often seem inexplicable. In many
instances, people feel that the symptoms are growing, expanding, and becoming incapacitating.
Obsessive-compulsive symptoms (OCS) in college students have been link to
suicidality. Researchers studied a cohort of 474 college students who attended mental health
screenings at two private universities and completed multiple self-report questionnaires. Data
show the presence of one or more OCS was associated with an increased odds ratio of suicide
risk of approximately 2.4. After controlling for depressive symptoms however, presence of OCS
was no longer a significant risk factor. Of the OCS assessed, only obsessions about speaking or
acting violently remained an independent risk factor for suicidality over and above depression. [18]
A study by Katz et al showed that panic attacks and panic symptoms in individuals with a major
mood disorder meeting criteria from the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV), may carry an increased risk of suicidal ideation. This ideation may
progress to suicide attempts, especially in individuals with prominent catastrophic cognitions. [19] An
example would be a woman with agoraphobia who becomes progressively more isolated and
depressed by her inability to leave her home.
Posttraumatic stress disorder
Survivors of trauma (eg, childhood sexual abuse, recent physical devastation, physical/emotional
abuse) struggle with flashbacks and nightmares. These individuals frequently alternate between
periods of hypervigilance and periods of psychic numbing.
Veterans of the wars in Iraq and Afghanistan experience a high rate of PTSDwith many
struggling with feelings of being damaged and with feelings of guiltand have a historically high
rate of suicide.[20, 21, 22]
Postdeployment readjustment problems affecting veterans of Operation Enduring Freedom (OEF)
and Operation Iraqi Freedom (OIF) are well documented, but the possible relationship of
readjustment stressors to the increase in military suicides is not.
Kline et al found that after adjusting for mental health and combat exposure, veterans with the
highest number of readjustment stressors had a 5.5 times greater risk of suicidal ideation than
those with no stressors. This suggests that suicide prevention efforts that more directly target
readjustment problems in returning OEF/OIF veterans are needed. [23]
Substance abuse

Substances can contribute to self-destructive behaviors in all 3 phases of their useintoxication,

withdrawal, and chronic usage. A depressed person commonly becomes acutely suicidal after a
few drinks. Similarly, some people can become suicidal after ingesting lysergic acid diethylamide
(LSD). Still others encounter depression during substance withdrawal and respond by killing
themselves. (See the graph below.)

Emergen
cy department visits for drug-related suicide attempts by adults aged 25 years or older, 2008. Courtesy of
Prevention Pathways, Substance Abuse and Mental Health Services Administration.

A person who engages in chronic alcohol and drug use often experiences a number of major
losses, including of his or her job, spouse, and family, and these, in turn, contribute to the
individual becoming suicidal.[13]
Even persons in drug recovery programs remain at risk. For example, patients in opiate
dependency programs, especially those with chronic pain, those with the availability of firearms,
those who use other street drugs, and those new to the program, are at particular risk. [24]
In a US study, Bohnert et al found that suicide and overdose are connected, yet distinct, problems.
Patients who have a history both of suicide attempts and of nonfatal overdoses may have poor
psychological functioning, as well as a more severe drug problem. [25]
The physical and mental health effects associated with methamphetamine (MA) use have been
documented; however, little is known about the effects of injection MA and suicidal behavior.
The Vancouver Injection Drug Users Study (VIDUS) found that MA injection was associated with
an 80% increase in the risk of attempted suicide, suggesting that individuals who inject MA should
be monitored for suicidal behavior. The study elicited information regarding sociodemographics,
drug use patterns, and mental health problems, including suicidal behavior. Of 1873 eligible
participants, 149 (8%) reported a suicide attempt. [26]
Delirium and dementia
Delirium and dementia involve the loss of memory, disorientation, hallucinations, delusions, and
poor judgment. These conditions often lead to self-destructive behavior. An example might be an
accountant who slowly starts to have difficulty remembering numbers and solving addition
problems. Although others might view these problems as minimal, he may feel that he is losing his
mind and career, leading him to take his own life.
Traumatic brain injury
Traumatic brain injury (TBI) has linked to increased risk of suicide. Bryan and Clemans have noted
the association of multiple TBIs as a risk factor. They studied a group of patients that included 161
military personnel referred for evaluation and treatment of suspected head injury at a military
hospital's TBI clinic in Iraq. They found depression, PTSD, and TBI symptom severity significantly
increased with the number of TBIs. They concluded that suicide risk is higher among military
personnel with more lifetime TBIs, even after controlling for clinical symptom severity.[27, 28]
Bulimia

Bulimia has been accompanied by suicidal activity. Predisposing factors include feelings of
loneliness, stimulant use, family history of psychiatric disorders, childhood abuse, and difficulty
dealing with the public.[29]

Sex
There is a distinct difference in suicide rates by sex. Men have a significantly higher rate of
completed suicides than do women. There are nearly 4 times the number of completed suicides
among men than among women. However, women have a much higher rate of suicide attempts.
[30]
Often, women select methods, such as an overdose of medication, that allow more time for
intervention. Men frequently use methods such as firearms, which are much more lethal.
Females more often use poison when attempting suicide. A study by Hoon et al investigated the
risk factors associated with the repetition of deliberate self-poisoning. The associated factors for
repeat suicide attempt were sex (female), living without a family, using antidepressants, and a
history of psychiatric treatment. Early psychological intervention and close observation is required
for patients meeting these criteria. (See the chart below.) [31]

Attempte
d suicide rates in males and females in a midsized to large municipality in Norway, 1984-2006.

Genetics
Some authorities believe that genetic factors alone may be involved in suicide, that suicide runs in
families, and that having a relative who commits suicide is indeed a risk factor. Therefore, a family
history of suicide is very significant. Careful assessments of family history of mental illness and
suicide should be a routine aspect of patient evaluation.
Studies continue to show the gene connection in suicidal behavior. Genes related to serotonin
have been implicated in histories of second suicide attempts.[32] In a study of postmortem brains
and living cohorts, Guintivano et al found evidence of a genetic and epigenetic link between
suicide and a single-nucleotide polymorphism in SKA2, a gene involved in cortisol suppression
and stress regulation.[33, 34] Many of the discussed mental illnesses (eg, bipolar disorder) are not only
risk factors for suicide but also have strong genetic components.

Family history
A family history of suicidal behavior represents a significant risk factor for the same behavior in
offspring. In some families, suicide constitutes a dynamic to deal with crises. Geulayov et al
reviewed the literature on these associations and found such a relationship. They also determined
that the association is stronger with maternal suicidal behavior versus paternal suicidal behavior
and that the risk is increased more in children than in adolescents or adults. [35]

Availability of firearms

The leading method of suicide remains firearms (see the chart below). [4, 36] When a person with a
depressed mood consumes alcohol and has a handgun available, the situation can easily turn
lethal.

Methods of suicide
used in the United States. Courtesy of Prevention Pathways, Substance Abuse and Mental Health Services
Administration.

Of 34,598 completed suicides, 17,352 used guns. [4] Therefore, a psychiatrist must inquire not only
into the patient's suicidal ideation and plans but also into the presence of firearms. Clinicians also
must know their state statutes concerning persons with mental illness possessing firearms. [37] Of
interest, the limiting of the purchasing of firearms by local and state background checks has
decreased the rate of suicide by guns.[38]
Data from the National Institute of Mental Health on the differences between men and women and
the method of suicide are as follows [30] :

Suicide by firearms - Males (56%), females (30%)

Suicide by suffocation - Males (24%), females (21%)
Suicide by poisoning - Males (13%), females (40%)

Physical illness
Suicide is often encountered in patients who have a severe medical problem. The risk for suicide
increases in the face of a protracted, painful, progressively debilitating disease.
For example, patients undergoing dialysis for end-stage renal disease have a higher rate of suicide
than that of the general population.[39] Other diseases conferring a higher suicide risk include
chronic obstructive pulmonary disease (COPD), cancer, human immunodeficiency virus (HIV)
infection/acquired immunodeficiency syndrome (AIDS), quadriplegia, multiple sclerosis, severe
whole-body burns, and chronic heart failure.

A study by Webb et al found a significant link between physical illnesses and suicidal behavior in
primary care patients. Coronary heart disease, stroke, chronic obstructive pulmonary disease, and
osteoporosis were linked with increased suicide risk among all patients. Elevated risk of suicide
was due to clinical depression in all patients, excluding those with osteoporosis.
However, 2 groups of women in the studythose younger than 50 years who were physically ill
and older women with multiple physical diseaseswere found to have an elevated suicide risk
even after depression had been adjusted for.[40]
Asthma has also been linked to suicide, particularly in young people. [41, 42] The combination of
cancer and age is particularly lethal. [43] Persons experiencing increasing intractable pain are at
particularly high risk for suicide.
There is a possible link to suicide in patients with migraine and fibromyalgia. Researchers
examined a population of patients with migraine and found that those who also had a diagnosis of
fibromyalgia (FM) had a high instance of suicide ideation and attempts. [111]

Life experiences
Certain recent life events can precipitate suicidal behavior. These include romance-related losses,
such as the termination of a love relationship or a divorce; a job termination, or the loss of a pet.
The acute loss can be devastating.[44]
A number of past life events are also linked to suicide. The most important is suicide by a family
member or a friend. Not infrequently, history of a father, mother, or sibling committing suicide
correlates with suicide by another member of that family.
Suicide by a friend may provoke others to duplicate the event; indeed, suicide has a contagious
aspect, especially among adolescents. [45] Not uncommonly, one suicide in a high school is followed
by other suicides or attempts. In fact, bereavement for a person who has completed suicide stands
as a significant risk factor. Researchers examined 3,432 eligible respondents aged 18-40 who
were bereaved by suicide of a friend or relative after the age of 10. Results showed that adults
bereaved by suicide had a higher probability of attempting suicide than those bereaved by sudden
natural causes, suggesting that bereavement by suicide is a specific risk factor for suicide attempt
among young bereaved adults.[112]
As discussed earlier, persons with PTSD are particularly vulnerable to suicide. These individuals
may have a history of physical, emotional, or sexual abuse. Damage to the person leads to selfdestructive actions.
One study found that sexual violence and having witnessed violence were significant predictors of
lifetime suicide attempts.[46] This study, which examined the possible link between trauma exposure
and suicidal behavior, was conducted with 4351 adult South Africans from 2002-2004 as part of
the World Health Organization (WHO) World Mental Health Surveys. A 2014 meta-analysis
reached similar conclusions.[47, 48] Future research is needed to better understand how and why
these experiences in particular increase the risk of suicidal outcomes.
Victimization by bullying is another experience that has emerged as a correlate to suicidal
behavior, and attention must be paid to this in the suicide assessment. In a landmark study by
Klomek et al of 5302 children in Finland born in 1981, the authors found evidence that bullying at
age 8 years was linked to self-destructive behavior later in life.[49] When controlling for depression
and conduct symptoms, suicide attempts and completions in later life in females were significantly
correlated to bullying. However, the same correlation was not apparent for males. [49]
More evidence that being bullied in childhood leads to self-injurious behavior in adolescence was
provided by a study conducted by Fisher et al. The authors analyzed data for 2141 children in the
UK and found that among children aged 12 years who had self harmed (2.9%; n=62), more than
half were victims of frequent bullying (56%; n=35). Exposure to frequent bullying predicted higher
rates of self-harm even after accounting for other risk factors such as emotional and behavioral
problems, low IQ, and family environmental risks.[50]

Economic instability and status

Times of economic change, especially economic depressions, have also been associated with
suicides. The start of the Great Depression in the United States was accompanied by a number of
suicides.

Job loss has long been associated with increased suicidal ideation and behavior. Emile Durkheim
demonstrated a correlation between times of economic decline and employment decreases and a
rise in completed suicides. However, there has always been the companion assumption that these
suicides occurred mostly among the adult population.
Gassman-Pines and colleagues have shown that youth suicidal activities are also exacerbated by
job loss. They looked at 1997 to 2009 data from the Youth Risk Behavior Survey and the Bureau of
Labor Statistics to estimate the effects of statewide job loss on adolescents' suicidal ideation,
suicide attempts, and suicide plans. They found job losses among 1% of a state's working-age
population increased the probability of adolescent girls and Blacks reporting suicide-related
behaviors by 2 to 3 percentage points. Job losses did not affect the suicide-related behaviors of
boys, non-Hispanic Whites, or Hispanics. They concluded that adolescents, like adults, are
affected by economic downturns.[51]
Durkheim noted that in times of major societal alternations, when the rules are in flux and people
do not know what is expected of them, the self-destructive rate increases. He had observed that
not only did the suicide rate increase with a rise in unemployment but also that a soaring economy
led to heightened suicide activity. He termed this period of major cultural changes anomie.
Poverty and low income, with concomitantly fewer options and opportunities, also correlate with
suicide.[11]

Media and the Internet

Media can be a suicidal factor in negative and positive ways. The Internet, and other media, can
provide information concerning "how-to" methods. A 2008 study found many Websites providing
specific techniques on suicide.[52] That same study also found many antisuicide sites and a
surprising number of prosuicide sites.
Books can also have a negative impact on suicide. A patient, after reading the bookFinal Exit, used
one of the methods described to complete a suicide. Furthermore, antipsychiatric Internet sites are
available that decry mental health explanations and, for example, show ways to be more effective
at being anorexic. The Internet has also been used to broadcast suicides and has been a tool for
the development of suicide pacts.[53]
However, a number of Web sites do provide encouragement for treatments, accounts of successful
interventions, and key resources.[54] In addition, individuals have used the Internet to take online
questionnaires that can indicate depression and suicide potential; some college students were
found to have sought treatment as a result of taking these surveys. [55]

Contagion
Suicidal behavior, especially amongst adolescents, has been linked to other adolescents complete
and attempted suicide. Swanson and Colman looked at the association between exposure to
suicide and suicidality outcomes in youth. They used baseline information from the Canadian
National Longitudinal Survey of Children and Youth between 1998-1999 and 2006-2007, with
follow-up assessments 2 years later. This included 8766 youth aged 12-13 years, 7802 patients
aged 14-15 years, and 5496 patients aged 16-17 years. They determined that knowing someone
who had committed suicide was associated with increased suicidality outcomes for all age groups.
Exposure to suicide predicts ideation and attempts. [56]

Psychodynamic formulation
Several individual psychodynamic ways of viewing suicide exist. In one situation, patients deflect
anger inward to hurt themselves when they want to strike out at others. An example would be a
young person taking a drug overdose to punish his or her parents after being grounded for
misbehavior.
Alternately, the psychoanalytic notion exists of incorporation and killing the interject. In this
situation, patients have unconsciously incorporated an ambivalently held object (eg, a family
member). For example, a man incorporates his father. He then attacks the interject (father) by
killing himself.

Impulsivity

In many cases, suicidal behavior results from a person acting impulsively. Burton and colleagues
showed that a lack of executive functioning in the form of poor impulse control inhibition represents
a suicide risk. Impulsivity can often separate people who just have suicidal ideation from those
who actually attempt suicide.[57]
However, Spokas et al have suggested that impulsive attempts have valid significance and are
similar to premeditated attempts with regard to completed suicide risk. [58] Hence, an assessment of
the patients impulse control is critical.

Other risk factors

A number of other factors are closely linked to suicide, including marital status, perceived/actual
incarceration, lack of exposure to daylight, and even geographic altitude.
Marital status
People who are married are less suicidal than are those who are single, divorced, or widowed.
Isolated individuals are at greater risk for suicide than are those involved with others and their
community.
Geographic altitude
A study by Kim et al described altitude as a risk factor for suicide. [59] Their study concluded that
when gun ownership, altitude, and population density are considered as predictor variables for
suicide rates on a state-by-state basis, altitude is a significant independent risk factor. Thus, the
higher the altitude, the higher the risk of suicide. [59] This association may be related to metabolic
stress associated with mild hypoxia in individuals with mood disorders.
Incarceration and hospitalization
If an individual feels or is indeed trapped, especially those who are incarcerated, they are at
suicide risk. Prisoners have a high rate of suicide; this is common during the first hours to first
week of being placed in confinement.[60, 61] In contrast, during the first week after a patient's
discharge from a psychiatric hospital or unit, the risk of suicide is particularly high. [62] For many, the
transition is difficult, challenging, and anxiety provoking.
The risk of suicide should be extended to all persons involved with the criminal justice system.
Webb et al determined that major health and social problems frequently coexist in this population,
including offending, psychopathology, and suicidal behavior.[63] Further prevention strategies are
needed for this group, including improved mental health service provision for all people in the
criminal justice system, even those found not guilty and those not given custodial services. Better
coordination is needed in public services to tackle coexisting health and social problems.
Lack of daylight
Lack of daylight correlates with depression and suicide. Regions with long, dark winters, such as
Scandinavia and parts of Alaska (eg, Nome), have high suicide rates. Indeed, persons with
seasonal affective disorder (SAD) who live in these regions experience depression in the absence
of sunlight and, hence, have a higher susceptibility to depression, which may lead to suicide.
Serum cholesterol
A correlation has long been noted between low levels of total serum cholesterol and suicidal
activity. Oli and associates found lower cholesterol levels in persons who attempted suicide,
suggesting serum cholesterol levels could possibly be used as a biologic marker for potential
suicide risk.[64]
Sleep problems
Sleep difficulty remains an indicator for not only depression and anxiety disorders but also a risk
factor for suicide. Bjrngaard and colleagues studied sleeping problems and suicide in 75,000
Norwegian adults for 20 years. They concluded that problems with sleeping, perhaps in
combination with or as a consequence of anxiety and depression, should be considered a marker
of suicide risk.[65]
Military suicides

There has been a recent dramatic increase in suicides among military personnel. In the search for
causes, researchers examined the association between deployment and suicide among all 3.9
million US military personnel who served during Operation Enduring Freedom or Operation Iraqi
Freedom. They also explored suicides that occurred after separation from military service.
Results did not support an association between deployment and suicide mortality. However, results
did show an increased rate of suicide associated with separation from military service regardless
of deployment status. Rates of suicide were elevated among service members who separated with
less than 4 years of military service or who did not separate with an honorable discharge. [66]
A study of more than 163,000 soldiers, with a focus on 9,650 soldiers who attempted
suicide, found that those never deployed and women were more than three times as likely to try
suicide. The study examined risk factors (sociodemographic, service related, and mental health),
method, and time of suicide attempt by deployment status (never, currently, and previously
deployed). The enlisted soldiers who had never been deployed accounted for 40.4% of all soldiers,
but 61.1% of those who attempted suicide (n = 5894), with the risk of suicide highest in the second
month of service. Risk among soldiers on their first deployment was highest in the sixth month of
deployment and for those previously deployed, risk was highest at 5 months after return. [67]
DHA
Although more studies are needed, a report by Lewis et al suggested that low serum
docosahexaenoic acid (DHA) levels may be a risk factor for suicide. The authors studied activeduty US military personnel and found that the risk of suicide death was 14% higher per standard
deviation of lower DHA percentage. Among men, the risk of suicide death was 62% greater with
low serum DHA status.[68]
Concussion
According to a 2016 study, concussion sustained from everyday or recreational activities
triples long-term risk of suicide. The increased risk applied regardless of patients' demographic
characteristics and was independent of past psychiatric conditions. Weekend concussions were
associated with a one-third further increased risk of suicide compared with weekday concussions.
[69, 70]

Epidemiology
Occurrence in the United States
Suicide represents the tenth leading cause of death in the United States and the third leading
cause of death for children, adolescents, and young adults. In 2014, there were 42,773 suicides in
the United States.[2]
Several suicide-related demographic factors often occur in the same person. For example, if a
male police officer with major depression and a significant problem with alcohol commits suicide
using his service revolver (which, unfortunately, happens not infrequently), 5 risk factors are
involved: sex, occupation, depression, alcohol, and gun availability.
In the United States, certain states have higher suicide rates than others, as illustrated by the map
below. The Western states have the highest suicide rates, with the exception of Vermont. In
addition, living in rural areas carries a higher risk of suicide than living in urban areas. [71]

Suicide
rates in the United States by region, 2000-2006. Courtesy of the US National Institute of Mental Health and
Centers for Disease Control and Prevention.

The top 15 causes of death (in persons aged 1-85+ years) in the United States in 2007, according
to the National Institute of Mental Health, are as follows [72] :

Heart disease - 615,616

Malignant neoplasms - 562,795
Cerebrovascular - 135,814
Chronic lower respiratory disease - 127,875
Unintentional injury - 122,387
Alzheimer disease - 74,629
Diabetes mellitus - 71,373
Influenza and pneumonia - 52,492
Nephritis - 46,304
Suicide - 34,592
Septicemia - 34,543
Liver disease - 29,185
Hypertension - 23,963
Parkinson disease - 20,056
Homicide - 17,984

International occurrence
Globally, a remarkable range in suicide rates exists. The highest rates for men are in Hungary and
Finland. The United States is in the middle, and the lowest rates are in Greece, followed by Mexico
and the Netherlands. Moreover, in certain cultures, suicide has been considered more acceptable
than in others. For example, the Japanese culture often regarded suicide as an honorable solution
to certain situations.
Remarkably, although suicide remains a major cause of death internationally, treatment of suicidal
people around the world is quite lacking. Bruffaerts and colleagues used World Health
Organization (WHO) data to conclude that most people with suicidal ideation and plans and who
have made suicide attempts do not receive treatment. This finding extended across various
different areas around the world, especially in low-income countries. [73]

Religion-related demographics

Religion may also play a role in suicide. Historically in the United States, Protestants have had a
higher rate of suicide than either Catholics or Jews. Some religions may encourage suicide in
situations of disgrace or for patriotic reasons.

Race-related demographics
In the United States, most suicides occur within the white population. The rate for white men in
2007 was 13.5 cases per 100,000 population; for black men, 5.1 cases per 100,000 population;
and for Hispanic men, 6.0 cases per 100,000 population.[30] However, the rate for Native American
and Alaska Native men was 14.3 cases per 100,000 population. [30]
Furthermore, in sampling surveys (one from 53 countries and one from 43 countries), Voracek et al
found that regardless of sex or age, people with a lighter skin color have a higher rate of suicide
than do those with darker skin color.[74]
Although suicide rates for children aged younger than 12 years are significant, they have rarely
been studied from a racial perspective. In 2015, researchers reviewed national mortality data on
suicide in children aged 5 to 11 years in the United States from January 1, 1993, to December 31,
2012. The results showed that although the overall suicide rate in school-aged children in the
United States appeared stable over the 20 years of study, there was a significant increase in
suicide incidence in black children and a significant decrease in suicide among white children. [75]

Sex-related demographics
The relationship between sex and suicide represents one of the most salient and enduring features
in suicide-related statistics. Men commit suicide far more frequently than women. In the United
States, the difference is quite striking. Suicide was the 7th leading cause of death for males and
the 15th leading cause of death for females, in 2007. [30]
However, women make 2-3 times more suicide attempts than men do.[76]Furthermore, the sex
differential continues in those who are suicidal who seek help; females are much more prone to go
for medical and psychiatric aid then men are.[77]
Although the facts can be interpreted in many ways, including as they relate to method (men use
firearms, and women use poison) and the ability to handle feelings, the fact remains that difference
in frequency related to sex is a powerful and relatively consistent finding across a wide range of
other demographic categories, such as age, socioeconomic factors, and region.

Association between Toxoplasma gondii infection and self-directed violence

A relationship between Toxoplasma gondii infection in womean and self-destructive behavior was
found in a study of 45,788 Danish women between 1992-1995.Toxoplasma- specific IgG
antibodies were measured in connection with childbirth, and Pedersen and colleagues concluded
that mothers with T gondii infection had an increased relative risk of self-directed violence
compared with noninfected mothers (1.53 vs 1.85; 95% confidence interval, 1.27-1.85). Increasing
IgG antibody levels appeared to indicate increased risk. [78]

Age-related demographics
In general, the suicide rate increases with age, with a major spike in adolescents and young
adults. In recent decades, the number of adolescent suicides has increased dramatically. The 2007
Youth Risk Behavior Surveillance showed that 6.9% of high school students had attempted suicide
in the year before the survey.[79]
In a study of 6483 adolescents aged 13-18 years of age and their parents, Nock et al found lifetime
prevalences of suicidal ideation, planning, and attempts of 12.1%, 4%, and 4.1%, respectively.
Most meet the criteria for at least 1 DSM-IV disorder. This led them to conclude that suicidal
behaviors are common among US adolescents. The rates are close to those found in adults. [80]
Although adolescents generally have a high suicide rate and are at risk, certain subcultures have
an even higher risk. One such subculture is called "alternative," which includes individuals who
describe themselves as "Goth," "Emo," and "Punk." Young and colleagues looked at 452 German
school students aged 15 years. They found that teenagers who were in the alternative subgroup
self-injured more frequently (45.5% vs 18.8%), repeatedly self-injured, and were 4-8 times more
likely to attempt suicide (even after adjusting for social background). The study concluded that
approximately half of these adolescents' self-injure, primarily to regulate emotions and to

communicate distress. However, a minority self-injure to belong to the group. Alternatively, some
subculture groups, such as "Jocks," channel anxieties into activities such as exercise. [81]
With increasing age, a critical relationship emerges with suicide. Geriatric suicide is extremely
prevalent. People older than 75 years have the highest rate of suicide. In 2007, the incidence of
suicide in persons aged 75 years and older was 36.1 for every 100,000 people, compared with the
national average of 11.26 suicides for every 100,000 people. [30] Suicide risk in various cities in
England has been found to be 67 times higher for older adults (60 years) presenting with selfharm than for older adults in the general population. The highest suicide rates were found among
men aged 75 years and older.[82] The older age group also maintains an alarming connection with
murder-suicides. (Note the chart below for suicide figures based on sex, race, and age.) [83]

Rate of
suicides in the United States by sex, race, and age. Courtesy of the US National Institute of Mental Health and
the Centers for Disease Control and Prevention.

Suicide rates by age have historically noted peaks in the adolescent/young adult group and in the
elderly. From 1999-2010, a significant increase (28.4%) was noted in the age-adjusted suicide rate
for adults aged 35-64 years by 28.4%; the rate rose from 13.7 per 100,000 population to 17.6 (p<
0.001) Among men aged 35-64 years, the rate increased 27.3%, from 21.5 per 100,000 population
to 27.3; the rate among women increased 31.5%, from 6.2 per 100,000 population to 8.1. The
greatest increases among men were found in those aged 50-54 years and 55-59 years. Suicide
rates increased with age among women, with the largest percentage increase found in those aged
60-64 years.[84]

Occupation-related demographics
Police and public safety officers are at increased risk for suicide. The long hours of work, the
scenes they witness daily, the availability of guns, and the silence encouraged by the profession
(keeping within the "wall-of-blue"), as well as alcohol usage and divorce, contribute to this risk.
Firefighters also have a high incidence of suicide. In a report by National Volunteer Fire Council,
they identified over 260 firefighter suicides since they started to compile data on their own rank's
suicide from 1880. They noted similar dynamic causes as those found in police suidides (eg,
PTSD, job stresses) and suggested prevention approaches. [85]
Physicians, especially those who deal with progressively terminally ill patients, as well as dentists,
also have a high rate of suicide. In the United States, the medical field loses the equivalent of a
medical school class each year by suicide. Perhaps, elements of obsessive and perfectionist
tendencies combined with personal feelings of isolation may contribute to this high number of self-

induced deaths. Gold and colleagues looked at the records of 31,636 completed suicides, of which
203 were physicians. They concluded that inadequate treatment and increased problems related
to job stress may be potentially modifiable risk factors to reduce suicidal death among
physicians."[86] They essentially concluded that doctors are under a great deal of stress and are
often reluctant to seek help.
In view of the high rate of physicians suicide, Eneroth and colleagues looked at suicidal ideation
among residents and specialist in a university hospital. Unsurprisingly, they found that some of
these doctors did indeed have suicidal ideation. They concluded that residents and specialists
require separate interventions based on their position in the medical hierarchy. The study also
found that supportive meetings resulted in a lower level of suicidal ideation among specialists
whereas empowering leadership helped reduce suicidal ideation among residents. [87]
Suicide risk in military personnel has been increasing, as demonstrated in the chart below.

Suicides in active-duty
and nonactive-duty US Army soldiers, 2003-2008. Data source: US Army.

Seasonal variances in suicide

Most suicides occur in the spring; the month of May particularly has been noted for its high rate of
suicide. The speculation is that during the winter and early spring, people with depression are
often surrounded by persons who are feeling downhearted because of the weather. However, with
the arrival of the spring season and the month of May, people who are depressed because of the
weather are cheered and people who are depressed for other reasons remain depressed. As
others cheer up, those who remain miserable must confront their own unhappiness.
A report from the Annenberg Public Policy Center (APPC) at the University of Pennsylvania
reported December 4, 2012 on the common misperception that year-end holidays are a more
frequent period for suicides compared with other times of the year. The APPC tracked press
reports on this belief and compared them with the number of actual daily suicide deaths in the
United States. It was determined that compared with other timeframes, the period from November

to January typically has the lowest daily rates of suicide for the year. The APPC suggests that the
belief that year-end seasonal holidays prompt increased suicide rates is simply a myth. [88]

The relationship between suicides and birthdays

Researchers examined the association between birthday and increased risk of suicide in the
general population as well as in patients receiving mental health services. Using Poisson
regression analysis, they observed an increased risk of suicide on day of one's birthday itself for
males in both the general population (IRR = 1.39, 95% CI = 1.18-1.64, p < .01) and the clinical
population (IRR = 1.48, 95% CI = 1.07-2.07, p = .03). This increased risk was especially significant
in males aged 35 years and older. In the clinical population, risk was restricted to male patients
aged 35-54 and risk extended to the 3 days prior to one's birthday. These results suggest that
birthdays are periods of increased risk of suicide, particularly for men, regardless of whether or not
they are receiving psychiatric care.[89]

Suicide in pregnancy
Although suicide during pregnancy and in the postnatal period is uncommon, it is associated with
several important risk factors. One UK study sought to identify potential risk factors by analyzing
data regarding suicides of 4785 women between the ages of 16 and 50 years. Of these women, 98
(2%) died during the perinatal period. Of the 1485 women who died by suicide between the ages
of 20 and 35 years, 74 (4%) died in the perinatal period. Results show that women who died from
suicide during the perinatal period were more likely to have received a diagnosis of depression
compared with women who died by suicide but who were not in the perinatal period. They were
also less likely to be receiving any active treatment at the time of death.[90]

Patient Education
It is critical for patients to appreciate that suicidal behavior reflects mental illness. Moreover, the
patient's family needs to see the patients behavior as a sign of an underlying problem. Family
members often struggle with a series of conflicting feelings about the patients suicidal activities.
Education and an opportunity to discuss their feelings can help.
Helpful Web sites for patients include the following:

American Association of Suicidology

NIMH - Suicide Prevention
NIMH Warning Signs of Suicide
US Centers for Disease Control and Prevention (CDC) Suicide Prevention
For patient education information, see the Depression Center, as well asDepression and Suicidal
Thoughts.

Assessing Suicide Risk

A clear and complete evaluation and clinical interview provide the information upon which to base
a suicide intervention. Although risk factors offer major indications of the suicide danger, nothing
can substitute for a focused patient inquiry. However, although all the answers a patient gives may
be inclusive, a therapist often develops a visceral sense that his or her patient is actually going to
commit suicide. The clinician's reaction counts and should be considered in the intervention.

Suicidal ideation
Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is
highly linked to completed suicide. Some inexperienced clinicians have difficulty asking this
question. They fear the inquiry may be too intrusive or that they may provide the person with an
idea of suicide. In reality, patients appreciate the question as evidence of the clinician's concern. A
positive response requires further inquiry.

Suicide plans
If suicidal ideation is present, the next question must be about any plans for suicidal acts. The
general formula is that more specific plans indicate greater danger. Although vague threats, such
as a threat to commit suicide sometime in the future, are reason for concern, responses indicating
that the person has purchased a gun, has ammunition, has made out a will, and plans to use the
gun are more dangerous. The plan demands further questions. If the person envisions a gunrelated death, determine whether he or she has the weapon or access to it.

The relationship between suicidal ideation, plans, and attempts

In 2014, 9.4 million adults aged 18 years or older who responded to the National Survey on Drug
Use and Health (NSDUH) reported they had thought seriously about trying to kill themselves at
any time during the past 12 months. Those who had serious thoughts of suicide were then asked
whether they made a plan to kill themselves or tried to kill themselves in the past 12 months. Of
the 9.4 million adults with serious thoughts of suicide, 2.7 million reported they had made suicide
plans, and 1.1 million made a nonfatal suicide attempt. Among the 1.1 million adults who
attempted suicide in the past year, 0.9 million reported making suicide plans, and 0.2 million did
not make suicide plans. Nearly one third of adults who had serious thoughts of suicide made
suicide plans, and about 1 in 9 adults who had serious thoughts of suicide made a suicide attempt.
In other words, more than two thirds of adults in 2014 who had serious thoughts of suicide did not
make suicide plans, and 8 out of 9 adults who had serious thoughts of suicide did not attempt
suicide. This data show that suicidal thoughts can serve as an indicator of suicidal plans and
attempts.[91]

Purpose of suicide
Determine what the patient believes his or her suicide would achieve. This suggests how seriously
the person has been considering suicide and the reason for death. For example, some believe that
their suicide would provide a way for family or friends to realize their emotional distress. Others
see their death as relief from their own psychic pain. Still others believe that their death would
provide a heavenly reunion with a departed loved one. In any scenario, the clinician has another
gauge of the seriousness of the planning.

Potential for homicide

Any question of suicide also must be coupled with an inquiry into the person's potential for
homicide. Suicide is often thought to represent aggression turned inward, whereas homicide
represents aggression turned outward. Because suicide constitutes an aggressive act, the
question regarding homicidal tendencies must be asked.

Additional questions
Collateral questions should be asked based on the reviewed risk factors. These questions deal
with any family members or friends who have killed themselves and include questions about
symptoms of depression, psychosis, delirium and dementia, losses (especially recent ones), and
substance abuse.

Signs and risk factors

The following is a list of 12 things that should alert a clinician to a real suicide potential:

Patients with definite plans to kill themselves - People who think or talk about suicide are
at risk; however, a patient who has a plan (eg, to get a gun and buy bullets) has made a clear
statement regarding risk of suicide
Patients who have pursued a systematic pattern of behavior in which they engage in
activities that indicate they are leaving life - This includes saying goodbye to friends, making a
will, writing a suicide note, and developing a funeral plan
Patients with a strong family history of suicide - Family history of suicide is especially
indicative of suicide risk if the patient is approaching the anniversary of such a death or the age
at which a relative committed suicide.
The presence of a gun, especially a handgun
Being under the influence of alcohol or other mind-altering drugs - Drug abuse is
especially significant if the drugs are depressants.
If the patient encounters a severe, immediate, unexpected loss - Eg, when a person is
fired suddenly or left by a spouse
If the patient is isolated and alone
If the person has a depression of any type
If the patient experiences command hallucination - A command hallucination ordering
suicide can be a powerful message of action leading to death.
Discharge from psychiatric hospitals - Patients are at suicide risk upon discharge from a
psychiatric hospital, which is a very difficult time of transition and stress; the structure, support,
and safety of the institution are no longer available to the patient; the patient feels apprehension
and is confronted with the reality of change, which translates into fright and vulnerability.

Anxiety - Anxiety in all of its forms leads to a risk for suicide; the constant sense of dread
and tension proves unbearable for some
Clinician's feelings - As mentioned earlier, regardless of what the patient says or does, it
matters if the clinician has a feeling that patient is going to commit suicide; such perceptions are
part of clinical judgment and are an important part of the suicide assessment and intervention.

Elevated inflammation index in patients with major depressive disorder

O'Donovan A et al found that individuals with major depressive disorder (MDD) who attempt
suicide or successfully achieve it have elevated inflammation compared with nonsuicidal patients.
They also determined that patients with MDD and high suicidal ideation had significantly higher
inflammatory index scores than controls. They used inflammatory index based on markers tumor
necrosis factor-, interleukin-6, interleukin-10, and C-reactive protein. They concluded
inflammation is associated with suicidal ideation in patients with MDD.[92]

Other sources of information

Utilize all of the information available when assessing suicide risk. In addition to the material
obtained through the clinical interview, use information from other sources, including family
interviews or interviews with friends or coworkers. First responders or other medical personnel
may also have key information. In addition, a suicide note may have been written.
A number of written and online tests will indicate the presence of a significant depression and
significant thoughts and plans for self-destruction. These include the following self-administered
tests:

Beck Depression Inventory

Hamilton Depression Rating Scale
HANDS (Harvard Department of Psychiatry/National Depression Screening Day Scale)
Depression Screening Questionnaire [93]

Minnesota Multiphasic Personality Inventory (MMPI)

Constant thoughts of death or self-harm appear to be highly indicative of suicide risk. Patients who
think about death or self-harm "nearly every day" as evidenced by their response to a particular
question on the Patient Health Questionnaire (PHQ-9) are at greater risk for making a suicide
attempt compared with those who do not have these types of thoughts. [94, 95]
In a study of 84,418 individuals with depressive symptoms who completed the PPHQ-9 at every
outpatient visit for depression over a 4-year period, researchers found that patients who reported
in response to Item 9 ("Over the last 2 weeks, how often have you been bothered by thoughts that
you would be better off dead, or of hurting yourself in some way?") that they thought about death
or self-harm "nearly every day" accounted for 53% of suicide attempts during the study period and
54% of the suicide deaths.[94, 95] Those who responded "nearly every day" to Item 9 had a relative
hazard ratio (HR) of 6.37 for suicide attempt, and individuals who responded "more than half the
days" had a relative HR of 4.12. A 91% increase in risk was observed with each one-step increase
in the reported frequency of thoughts of death or self-harm. [94, 95]
Using the Collaborative Longitudinal Study of Personality Disorders (CLPS), Yen et al found that
the predictive power of the self-harm subscale of the Schedule for Nonadaptive and Adaptive
Personality (SNAP) may be a helpful screening tool for risk of suicide attempts in nonpsychotic
psychiatric patients.[96]
Ballard et al, in a study to determine how children react to suicide screening in an emergency
department (ED), suggested that pediatric patients supported suicide screening in the ED. Further
studies are needed to evaluate the impact of such screening on referral practices and to link
screening efforts with interventions.[97]

Patient History
A host of thoughts and behaviors are associated with self-destructive acts. Although many assume
that people who talk about suicide will not follow through with it, the opposite is true; a threat of
suicide can lead to the completed act, and suicidal ideation is highly correlated with suicidal
behaviors.
Numerous activities are associated with committing suicide, including the following:

Making a will

Getting the house and affairs together

Unexpectedly visiting friends and family members
Purchasing a gun, hose, or rope
Writing a suicide note
Visiting a primary care physician
With regard to the last item, a significant number of people see their primary care physician within
3 weeks before they commit suicide. They come for a variety of medical problems, but rarely will
they state they are contemplating suicide. Therefore, the practitioner must pay attention to the
entire person; the physician must look for factors in the patient's life beyond the chief complaint.

Suicide-related characteristics
Individuals who are suicidal have a number of characteristics, including the following:

A preoccupation with death

A sense of isolation and withdrawal
Few friends or family members
An emotional distance from others
Distraction and lack of humor - They often seem to be "in their own world" and lack a
sense of humor (anhedonia)
Focus on the past - They dwell in past losses and defeats and anticipate no future; they
voice the notion that others and the world would be better off without them.
Haunted and dominated by hopelessness and helplessness - They are without hope and
therefore cannot foresee things ever improving; they also view themselves as helpless in 2 ways:
(1) they cannot help themselves, and all their efforts to liberate themselves from the sea of
depression in which they are drowning are to no avail; and (2) no one else can help them

Mental Status Review

The mental status review is designed to focus on evaluating an individual's potential for committing
suicide.

Appearance
In addition to noting the dress and hygiene of patients who are depressed (eg, disheveled,
unkempt and unclean clothing), the clinician should assess these individuals for other signs of
suicide risk. First, look for physical evidence of suicidal behavior. This includes wrist lacerations
and neck rope burns. Be aware that more than 1 sign can indicate suicidal behavior. In one
example, a woman who was brought to an emergency department because she had cut her left
wrist was found, on physical examination, to have 5 vertical lacerations on her abdomen.

Affect
Depression and anxiety are commonly seen in people who are suicidal. One specific emotion of
concern is the patient exhibiting a flat affect when describing his or her thoughts and plans of
suicide and self-destructive behavior.

Thoughts
Three types of thought changes represent areas for major focus and concern. The first consists of
command hallucinations telling the patient to kill himself or herself. These are usually auditory in
nature and often take the form of the deity's voice (eg, "I hear God commanding me to kill myself,
because I am bad").
The second type consists of delusions. These include, "The world and my family would be better
off with me dead" or "If I take my life, I will be reunited in heaven with my mother."
The third type of thought involves the obsession of a patient wanting to take his or her own life.
Some patients focus their lives on their suicide. (See the chart below.)

Suicidal
thoughts and behaviors among adults by age group, 2008. Courtesy of the US Substance Abuse and Mental
Health Services Administration National Survey on Drug Use and Health.

Suicide and homicide

Inquiring into suicide potential is an absolute requirement. The more specific the ideas and plans
for suicide, the greater the possibility of suicide. Those with plans to purchase a gun exhibit a clear
danger.
In addition to suicide inquiry, the clinician must ask about homicidal potential. Aggression turned
inward is suicide; aggression turned outward is homicide. Homicide needs to be inquired about for
the following reasons:

It is part of a complete mental status examination

There is linkage between the homicide and suicide - For example, in adolescents, 2 of the
4 leading causes of violent death are homicide and suicide [79]
Although infrequent, homicide/murder and suicide are a reality [83]

Judgment, insight, and intellect

An assessment of the patients judgment is important. How a person has handled stress and how
he or she will handle it in the future are major concerns. Keep in mind that the less judgment the
patient has, the greater the potential for suicide. Impaired decision making is associated with
suicidal behavior in both adults and adolescents.[98]
It is important to note, for example, how the individual perceives attempts at suicide. The person
who sees an overdose as a cry for help has better insight than the person who awakes from an
overdose and says, "I wish I were dead."
The key idea with intellect assessment is to determine whether the person understands the
sequences of his or her behavior. For example, did the person know that walking into traffic would
be dangerous?

Orientation and memory

The focus of this part of the mental status review is to determine if the person is delirious or has
dementia. In either case, the patient, as a result of disorientation and loss of recollection, can
perform many self-destructive behaviors.

Prevention and Intervention

Prevention

Responding to calls for greater efforts to reduce youth suicide, the Garrett Lee Smith (GLS)
Memorial Act to date has provided funding for 68 state, territory, and tribal community grants, and
74 college campus grants for suicide prevention efforts.[99]
Garraza and colleagues examined the effectiveness of the GLS program for suicide prevention in
youths. They compared 466 counties implementing the GLS program between 2006 and 2009 with
1161 counties that shared key preintervention characteristics but were not exposed to the GLS
program. The results show that counties implementing the activities had significantly lower suicide
attempt rates among youths 16 to 23 years of age in the year following implementation of the GLS
program than did similar counties that did not implement GLS program activities (4.9 fewer
attempts per 1000 youths).[100]
Screening Tests as Early Detection of Depression as a Suicide Prevention Tool
Screening tests such as item 9 of the Patient Health Questionnaire (PHQ) depression
module offer one possible avenue in detecting potential for self-destructive behavior. Dr. Simon
and colleagues looked 509,945 adult outpatients completing 1,228,308 PHQ depression
questionnaires during visits to primary care, specialty mental health, and other outpatient providers
between January 1, 2007 and December 31, 2012. (Simon, 2016) They found the cumulative
hazard of suicide death during 2 years ranged from approximately 0.04% among those responding
"not at all" to 0.19% among those responding "nearly every day. Although they also reported 39%
of suicide attempts and 36% of suicide deaths within 30 days of completing a PHQ occurred
among those responding "not at all" to item 9. However, they concluded in community practice,
response to PHQ item 9 is a strong predictor of suicide attempt and suicide death over the
following 2 years. Screening tests represent one clinical approach to identify patients at suicide
risk. (Simon, 2016)

Intervention
The treatment of a suicidal patient involves a 2-phase process. First and foremost, the patients
safety must be assured; this is the intervention. Intervention is based on the application of risk
factors coupled with a clinical inquiry. The second step is treatment aimed at diagnosing and
treating the underlying mental disorder.
First phase of intervention
In many cases, swift, decisive intervention can prevent a person from committing suicide. Because
of this preventable aspect of suicide, recognizing and taking action if the potential arises is critical.
Based on the clinical assessment and all of the information available, if the person is indeed
suicidal, the intervention should consist of multiple steps.
The individual must not be left alone. In the ED, such a recommendation is handled easily by
hospital security personnel. In other settings, summon assistance quickly. In an isolated place, call
911. Involve family or friends; they can remain with the patient while treatment arrangements are
made.
Remove anything that the patient may use to hurt or kill him or herself. Remove sharp or
potentially dangerous objects. Ask the patient for any weapon, such as knives or pills, and secure
them away from the patient.
The suicidal patient should be treated initially in a secure, safe, and highly supervised place.
Inpatient care at a hospital offers one of the best settings. Most managed care companies
recognize the medical necessity of hospitalization in situations in which the suicide danger is
acute.
A study of the association between the provision of mental health services and suicide rates found
that removing ligature points (places where things like ropes could be attached to) was associated
with significant reductions in the overall psychiatric inpatient suicide rate and in the rate of inpatient
suicide by hanging.[101]Similarly, assessing other available sources of self-destructive implements
such as pills and guns is critical.
Patients who attempt to commit suicide with prescribed medications represent one of the greatest
clinical challenges. The dilemma involves balancing the fact that psychotropic drugs alleviate
mental illness symptoms with the reality that some patients will use the very same medications to

commit suicide. Gjelsvik et al highlight this conundrum in their study in which patients who engage
in deliberate self-poisoning had a greater prescribed medication load compared with the general
population, and that this medical load is more important in determining self-poisoning episodes
than the timing of collection of prescribed medication prior to an episode. [102] This study points out
the need to pay attention to the amount of stockpiled medications available to the potentially selfdestructive patient.
Second phase of intervention
After the initial intervention, which usually includes hospitalization, it is critical that there be in place
an ongoing management treatment plan. The heart of the second phase of the intervention is
addressing the underlying cause of the self-destructive behavior. If the patient has selected suicide
to escape physical pain, then a comprehensive pain management program must be initiated. If the
patient is depressed, then the depression must be treated with medication and psychotherapy. If
the suicide attempt has been in response to the patient with schizophrenia struggling with
destructive hallucinations and delusions, then these must be aggressively treated. The key
remains an accurate assessment and diagnosis followed by a comprehensive treatment plan.
One would expect that intense intervention efforts following a suicide attempt would be effective in
lowing morbidity and mortality. To test this theory, Morthorst et al assessed the efficacy of
outpatient intervention in patients older than 12 years admitted to regional hospitals in
Copenhagen with a suicide attempt within the past 14 days. Intervention consisted of assertive
outreach that provided crisis intervention and flexible problem solving. This approach, assertive
intervention for deliberate self-harm, incorporated motivational support and actively assisted
patients to scheduled appointments. The study followed 243 patients for 12 months. Rates of
subsequent suicide attempts did not differ significantly between the intervention and control
groups. Although this study did not show the advantage of an intensive follow-up care, it does point
out the need for a clear, definite, and defined postsuicide attempt treatment plan. [103]
A study of brief CBT in a cohort of active-duty military personnel in Colorado who either attempted
suicide or experienced suicidal ideation found the treatment effective in preventing follow-up
suicide attempts. Over the course of two years, 8 out of 76 participants (13.8%) in treatment as
usual combined with brief CBT and 18 participants out of 76 (40.2%) who did not receive CBT
made at least one attempt at suicide. Data show that soldiers treated with brief CBT were
approximately 60% less likely to attempt suicide than soldiers who did not receive the therapy.[104]

Pharmacologic Therapy
Medication use is based on the patients underlying mental disorder. Each mental disorder requires
specific medications and adequate treatment of the underlying psychiatric illness consistently
appears to be the most effective use of medication in suicidal patients. For example, a patient with
a major depression feels hopelessness and helplessness. These perceptions lead the individual to
suicidal ideation and plans. Once that persons safety has been assessed and assured, the use of
an antidepressant is indicted to lift and reverse the despair.
Alternatively, a patient with schizophrenia experiences self-destructive command hallucinations
telling that person to commit suicide. Once the patients safety has been established, an
antipsychotic medication is indicated.
The key to diagnosis is taking the patients psychiatric history and conducting a thorough mental
status examination.

Repetitive TMS
In a randomized study of 41 adult inpatients in suicidal crisis, high-dose repetitive transcranial
magnetic stimulation (rTMS) to the left prefrontal cortex, applied 3 times daily for 3 consecutive
days, yielded a significantly larger and more rapid reduction in scores on the Beck Scale for
Suicide Ideation (SSI) than sham rTMS did.[105, 106]All study subjects had comorbid posttraumatic
stress disorder, mild traumatic brain injury, or both.

Postvention
This section details steps a clinician should take in cases of completed suicide. Practitioners must
work with the patient's family and friends, as well as with the other patients who knew the
deceased.[107]

Upon learning of the death of a patient, focus on the immediate situation. Reschedule other
patients and, whenever possible, meet with the family. Family members appreciate the clinician's
interest and the opportunity to voice their feelings and reactions. In some situations, the family may
have expected the outcome. In others, they may be hurt and angry. The clinician's job is to be
responsible and responsive to them. This intervention may require more than 1 session. Be
available to family members, listen to them, and share their loss.
Often, other patients knew the deceased person. Without violating confidentiality, provide extra
attention to these patients. This could include sessions to allow them to express their reactions to
the death and loss. If the patient who committed suicide was an inpatient, convening a group
meeting and discussing the other patients' reactions is important. The staff should also have an
opportunity to discuss their feelings.
Finally, the practitioner must take time to review and discuss the event. Often, seeking a senior
clinician is effective. The therapist needs an opportunity to recover and heal. Later, a psychological
autopsy can be performed, but in the acute phase, the clinician requires sympathy and support.