Navaneelan T. Suicide rates: An overview. Statistics Canada. https://www150.statcan.gc.ca/n1/pub/82-624-x/2012001/article/11696-eng.htm. Updated June 16, 2017. Accessed October 22, 2019.
McDowell AK, Lineberry TW, Bostwick JM. Practical suicide-risk management for the busy primary care physician. Mayo Clin Proc. 2011 Aug;86(8):792-800. doi: 10.4065/mcp.2011.0076. Epub 2011 Jun 27. Review. PubMed PMID: 21709131; PubMed Central PMCID: PMC3146379.
Perlman CM, Neufeld E, Martin L, Goy M, Hirdes JP. Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health care Organizations. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute. 2011.Suicide Prevention Resource Center. Suicide assessment five-step evaluation and triage (SAFE-T) pocket card. http://www.sprc.org/resources-programs/suicide-assessment-five-step-evaluation-and-triage-safe-t-pocket-card. Accessed October 22, 2019.
Definition, Etiology, PathogenesisTop
Suicide is a deliberate action taken to intentionally end one’s life. In 2009 there were 3890 completed suicides in Canada, a rate of 11.5 per 100,000 people. The suicide rate for males was 3 times higher than the rate for females (17.9 vs 5.3 per 100,000). Although suicide deaths affect almost all age groups, those aged 40 to 59 had the highest rates, with risk increased among individuals who are single, divorced, or widowed. Overall, suicide is the 9th leading cause of death, the 2nd leading cause in young adults aged 15 to 24 years.
Suicidal ideation is any thought about ending one’s life, from vague and fleeting to intense and detailed. Passive suicidal ideation is the presence of thoughts about wanting or wishing to be dead, such as hoping to die from a terminal illness or to go to sleep and not wake up.
Serious thoughts of suicide, plans for suicide, and suicide attempts are surprisingly common in the general population. However, death by suicide is still a low-rate event and impossible to predict accurately. Although relatively uncommon, suicide has a lifelong and profound effect on the families, friends, and physicians of the person who dies by suicide.
Suicide risk factors (Table 12.12-1) are associated with an overall increased risk of suicide but do not reflect the immediacy of this risk. Risk factors for patients in the emergency department or admitted to a psychiatric or nonpsychiatric (medical or surgical) unit include previous attempted suicide, especially if recent, treatment with antidepressants, presence of physical health problems (eg, chronic pain), poor health prognosis, social stressors, hopelessness, and substance abuse. Additional risk factors among inpatients include anxiety, agitation, delirium, and insomnia.
Warning signs are specific symptoms or behaviors that are acute or subacute in nature and which are associated with an elevated risk of suicide. Warning signs can be identified, explored further, and addressed with clinical and psychosocial interventions. Anxiety, psychomotor agitation, sleep problems, poor concentration, hopelessness, social isolation, and excessive or increasing use of alcohol or drugs are all worrisome factors that can be modified with prompt interventions. Difficulties with impulse control or anxiety in the context of depression can progress to suicidal behavior. On inpatient medical or surgical units the presence of warning signs should be a cue to exploring thoughts of suicide with the patient. Warning signs of particular concern in medical/surgical inpatients include both acute mental and motoric agitation.
Self-injurious behaviors (parasuicide) are deliberate, repetitive, impulsive actions to harm oneself without lethal intent. These behaviors are associated with difficulty expressing emotions and require psychiatric assessment and treatment. Self-injurious behaviors are a risk factor for suicide.
There are many theories proposed to understand suicidal ideation. It is associated with hopelessness, perception of having unsolvable problems, and wanting to escape one’s problems. One theory proposes that suicide is the result of perceived burdensomeness, thwarted belongingness, and acquired capability (ie, the view that one’s existence burdens family, friends, and/or society; belief that the need to belong is unmet; and circumstances).
Clinical Features and AssessmentTop
Suicidal ideation is associated with depressive disorders, anxiety disorders, and other psychiatric illnesses. In a nonpsychiatric hospitalized setting, patients experiencing stresses, psychiatric illness, or physical distress may have thoughts of suicide. Patients identified as being at elevated risk or who have made a medically serious suicide attempt should have a full psychiatric evaluation.
It is essential that a suicide risk assessment be performed in a face-to-face interview. Patients are more likely to trust and share their thoughts of suicide with health-care providers showing empathy and listening nonjudgmentally.
All physicians should be able to screen for suicide. Include questions about depression and suicidal ideation during the review of systems if the topic has not yet been touched upon. Effective screening questions are, “Do you ever have thoughts that life is not worth living?” or “Do you ever wish you could go to sleep and not wake up?” A positive response to either of these nonjudgmental questions leads naturally to questions exploring the nature of the patient’s thoughts (“What sorts of thoughts have you had?”). The assessment needs to include questions about the frequency and intensity of thoughts of suicide, specific plans, protective factors, and any actions taken to prepare for death. It is important to explore any prior suicide attempt, especially if it has occurred within several weeks of the assessment. Clinicians should include assessment of agitation, anxiety, and hopelessness in their evaluation. It is important to understand that exploring the patient’s thoughts of suicide will not increase the risk of an attempt while it may decrease the risk by giving the patient the possibility to share distressing thoughts. Seek collateral information from family members and health-care professionals involved in the patient’s care.
A number of screening or clinical evaluation tools are available (eg, Suicide Risk Assessment Guide at the website of the Canadian Patient Safety Institute; Columbia-Suicide Severity Rating Scale; American Foundation for Suicide Prevention; SAFE-T at the website of SAMHSA-HRSA Center for Integrated Health Solutions). It is likely that none replaces careful clinical interview, thoughtful assessment, and reasonable level of clinician alertness, but they may be useful for ensuring all risk factors have been considered and for learning effective questions for risk assessment.
1. General considerations: Interventions depend on the evaluation of risk. Patients who have made a medically severe suicide attempt or disclose active suicidal ideation and intent need prompt assessment by a mental health professional and a secure setting with no access to lethal means. Delirium and a history of impulsivity or addiction are factors that increase the risk of unpredictable behavior and risk of suicide for nonpsychiatric inpatients. These individuals also need a secure setting and close observation.
Factors to consider in determining intervention include the presence of suicidal ideation, changes in the level of ideation or intent, warning signs, risk factors, and collateral information. Interventions include pharmacotherapy, structured psychotherapy modalities, reducing access to lethal means, community-based crisis interventions, and hospitalization for higher-risk patients.
2. Hospitalization: A patient may be hospitalized for psychiatric reasons or for conditions requiring medical or surgical interventions. When elevated suicide risk is the determining factor, there is usually acute psychiatric illness requiring inpatient treatment and/or emotional dysregulation. Patients assessed as being at elevated risk of suicide may require involuntary commitment if they refuse to stay in hospital or require physical or chemical restraints to prevent harm to themselves or others. Nursing staff provide therapeutic care to suicidal patients. Engagement nursing (as opposed to simply observational nursing care) has been associated with increased patient and staff job satisfaction.
3. Pharmacotherapy: Treatment of suicidal ideation depends on the underlying stressors and psychiatric illness or illnesses. For patients at elevated risk of suicide, consider choosing a medication with low lethality in overdose and/or prescribing limited drug amounts (weekly dispensing).
For patients with bipolar disorder, there is evidence that lithium prophylaxis may be associated with reduced risk of suicide.Evidence 1Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Low Quality of Evidence (low confidence that we know true effects of the intervention). Quality of Evidence lowered due to the observational nature of studies and indirectness. Lewitzka U, Jabs B, Fülle M, et al. Does lithium reduce acute suicidal ideation and behavior? A protocol for a randomized, placebo-controlled multicenter trial of lithium plus Treatment As Usual (TAU) in patients with suicidal major depressive episode. BMC Psychiatry. 2015 May 19;15:117. doi: 10.1186/s12888-015-0499-5. PubMed PMID: 25986590; PubMed Central PMCID: PMC4458032. Clozapine, in comparison with olanzapine, is likely associated with a reduced risk of recurrent suicidal behavior in persons with schizophrenia considered to be at high risk for suicide.Evidence 2Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to indirectness. Meltzer HY, Alphs L, Green AI, et al; International Suicide Prevention Trial Study Group. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry. 2003 Jan;60(1):82-91. Erratum in: Arch Gen Psychiatry. 2003 Jul;60(7):735. PubMed PMID: 12511175. Both should only be started after consultation with a psychiatrist, as each requires monitoring, has significant adverse effects, and is toxic in overdose.
4. Psychotherapy: Several talk therapies have been found effective in reducing the risk of suicide and/or suicidal ideation. Interventions found effective are generally structured manual-based therapies delivered in individual or group settings. Therapists are not available in all communities.
Dialectical behavior therapy (DBT) and the Collaborative Assessment and Management of Suicidality (CAMS) have been found effective for preventing suicide and are generally considered outpatient treatments. DBT is a year-long structured therapy that guides patients through the development of emotion regulation and distress tolerance skills as well as behavior skills to build a life worth living. Treatment includes individual and group sessions, phone coaching, and therapist consultation. Some inpatient settings offer DBT groups. CAMS is a briefer structured intervention that focuses on identifying factors leading to suicidal ideation and employs problem-solving strategies to address these. Patients must be carefully selected and be motivated to make changes in their lives to reduce their thoughts of suicide.
Skills for Safer Living is a 20-week outpatient psychotherapy group for people who have made 1 or more suicide attempts. Less well-known than DBT or CAMS, it uses peer leaders with lived experience.
5. Electroconvulsive therapy (ECT): While in specialized settings, patients at very high risk of suicide should be considered for ECT.
6. Secure hospital environment: Guidelines are available for providing secure inpatient settings that focus on minimizing environmental risks. Mental health units are now designed to reduce the risk of hanging from doors, windows, shower heads (ligature points) and to minimize access to lethal means (sharps and other medical equipment in locked areas only, elimination of plastic bags). Medical and surgical units are rarely designed to these standards. Additional staffing and vigilance may be required to minimize risk.
7. Access to means: Reducing access to lethal means is a harm-reduction strategy for suicide prevention. Patients expressing suicidal ideation should be asked about access to firearms, lethal medications, and other materials for suicide methods they are considering. It is impossible to make community settings safe but limited access to lethal means can reduce impulsive suicide attempts. Public health interventions focus on community-based approaches to reducing access to lethal means (eg, barriers at bridges and railway tracks). In the hospital, medical and surgical unit personnel may need to change practices to reduce access to lethal means to increase the safety of the hospital environment for a suicidal patient (eg, not storing sharps in the patient’s room, removing cords).
8. Crisis support: A growing number of communities have access to crisis supports. This can include telephone crisis lines, drop-in centers for mental health support, and crisis outreach teams that assess people in their home or other community setting. Training for police results in fewer persons brought to emergency departments for assessment. Patients with suicidal thoughts managed in the community may benefit from a safety plan that describes actions, contacts, and strategies to cope should they develop active suicidal ideation.
Suicide prevention is a public health issue with initiatives that can be targeted at individual, health-care system, community, or societal level. Population-based approaches include education initiatives, reduced access to lethal means, and stigma reduction. Primary interventions include training family doctors to better assess and treat depression and substance abuse treatment. Targeted interventions focus on groups at elevated risk of suicide such as lesbian, gay, bisexual, transgender, questioning/queer (LGBTQ) youth and aboriginal persons.
Many hospitals have implemented suicide prevention measures such as staff training, patient care protocols, and environmental reviews to minimize risks. Zero Suicide is a hospital-based quality improvement initiative to reduce suicide rates of registered inpatients. It includes a specific set of tools and strategies, many evidence-based, that a health-care organization can implement to reduce suicides in inpatient and outpatient populations (visit zerosuicide.sprc.org). The comprehensive approach to suicide prevention requires support from leadership, education of staff, assessment and treatment protocols, and measurement of indices associated with suicide prevention.
Suicide of a hospital inpatient on a psychiatric or nonpsychiatric unit is an uncommon but tragic event. Suicide of a hospital patient is a critical incident and should be explored in a death review that examines circumstances of the death and seeks to prevent similar deaths but does not find fault or assign blame. Physicians and other health-care providers who lose a patient to suicide should be offered support to cope with the loss in individual or group counseling.
– Family history of suicide
– Family history of child maltreatment
– Previous suicide attempt
– History of mental disorders, particularly clinical depression
– History of alcohol and substance abuse
– Feelings of hopelessness
– Impulsive or aggressive tendencies
– Cultural and religious beliefs (eg, belief that suicide is noble resolution of a personal dilemma)
– Local epidemics of suicide
– Isolation, a feeling of being cut off from other people
– Barriers to accessing mental health treatment
– Loss (relational, social, work, or financial)
– Physical illness
– Easy access to lethal methods
– Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts
Source: Centers for Disease Control and Prevention. Risk Factors for Suicide. https://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html. Accessed September 26, 2019.