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suicide

also see suicidal ideation Etiology: 1) risk factors for completed suicide a) male gender b) > 60 years of age [5] c) widowed or divorced d) Caucasian or native American e) availability of firearms f) life stressors - death of spouse - economic woes, loss of job g) chronic or terminal illness - medical conditions with increasing disability associated with increased risk [48] - mental illness requiring hospitalization associated with very high risk such that disability associated with medical illness has no additional impact [48] - severe infection, especially hepatitis, HIV1 infection [21] h) chronic pain [29] - back pain, cancer pain, arthritis i) major depression [3] (major cause in elderly [30]) - hopelessness is the best predictor of suicide in the elderly [46] j) traumatic brain injury [28] k) diagnosis of dementia within 1st year of diagnosis [40,41] l) unemployment [9] m) duration of sunshine correlates positively with risk up to 10 days before suicide, but negatively with risk 14-60 days before suicide [4] n) enforcing restrictions on reproductive care including abortion linked with ~6% rise in suicide among women of reproductive age [42] 2) Risk factors for attempted suicide a) female gender b) < 30 years of age c) substance abuse d) mental disorders [6] - depression - borderline personality disorder - PTSD - anxiety disorder - psychotic disorder - recent diagnosis of dementia or mild cognitive impairment [34] e) nightmares? f) prior suicide attempts g) disrupted family situation 3) suicidal ideation - veterans who have killed in combat are at increased risk [8] - having a parent die during childhood [16] - cerebral concussion ~ 3-fold risk [18] - self neglect, RR~3-fold (Chinese Americans) [37] - elder mistreatment, including elder neglect - self-reported discrimination ~ 2-fold risk [37] 4) methods of suicide - firearms are the most common method used for suicide among males - for women, poisoning was the most common method [19] - suffocation is the most common method used among females 10-24 years of age (includes hanging) [15] - - 25% of suicides occur by suffocation - drug ingestion is the most common method used for attempted suicide - opioid use disorder is a risk factor for suicide [39] Epidemiology: 1) 33% of people have suicidal ideation during their lifetime 2) 9th leading cause of death 3) 3rd leading cause of death in adolescents (age 15-24) - gay, lesbian, bisexual, or questioning adolescents 3-fold more likely to attempt suicide than their heterosexual peers [25] 4) white males > 85 years of age have highest rate 5) rates in elderly tend to be underestimated because they are easily confused with medical complications 6) 20 cases per 100,000 in > 65 age group vs 12 per 100,000 in younger population - suicide attempts highest 21-34 age group, - suicide highest 45-64 age group [24] 7) deteriorating physical health is more important than psychiatric illness in predicting self-harm in the elderly [7] 8) 2nd leading cause of death among persons 10-24 years of age [15] 9) one person dies by suicide every 40 seconds worldwide [13] 10) increase in suicide in U.S. from 1999-2014 - suicide among people 35-64 years of age increased 28% from 1999 to 2010 [11] - ~2% yearly increase in suicides from 2004-2013 [24] 11) suicide rate in 2014 3-fold greater in males than females (20.7 vs 5.8 per 100,000) [19 12) increase in suicide 1999-2016 [26] - suicide rate increased > 30% in 25 states - North Dakota with highest increase of 58% - in 2015, 18% of suicides had served in the military - >50% of cases had no documented mental health disorder 13) suicide among U.S. health care workers 2008-2019 higher than among non-health care workers for registered nurses, health technicians, & health care support workers, but not physicians [44] Pathology: - reduced brain serotonin or 5-hydroxy indoleacetic acid (5-HIAA) levels Diagnosis: 1) screen for suicidal ideation* a) asking does not precipitate suicidal thoughts b) 75% of suicidal patient seek physician help within 6 months of committing suicide c) most patients are reluctant to discuss suicidal thoughts without encouragement 2) assess risk a) current stressors b) presence of depression c) drug (including alcohol) abuse d) socioeconomic risks 1] gender 2] age 3) imminent risk a) suicidal ideation b) reasonable plan c) lethal method d) co-existing psychiatric disease 1] psychosis 2] depression 3] drug dependence e) lack of social support * USPSTF concludes that current evidence is insufficient to assess the balance of benefits & harms of screening for suicide risk in the adult population, including pregnant & postpartum women & older adults [43] Complications: - 5% with first suicide attempt die in the initial attempt or within the year [22] Management: 1) Intervention: a) imminent risk (active suicidal ideation) - don't leave the patient alone - immediate psychiatric hospitalization - ketamine may be useful for suicidal crisis [38] b) short term - involve family or close friends - remove access to methods - close follow-up & counseling c) psychosocial treatment [17] - similarities to cognitive behavioral therapy - identify triggers for suicidal ideation - formulate plans to counter suicidal ideation (if then) d) psychocatalysis (catch patient offguard) to engage withdrawn patient the morning after unsuccessful attempt [23] e) a safety intervention begun in the emergency department followed by post-discharge phone calls may help reduce suicidal behaviors among veterans [27] 2) Prevention: a) suicide awareness education b) social support - school & community support programs - peer support programs - social support & sense of belonging are protective against suicide in men [12] - higher minimum wage associated withe lower suicide risk [32] c) hospital & police programs to support victims of violence & at risk groups d) crisis intervention - fellow students after successful suicide e) firearm restrictions & safeguards f) early detection & screening programs g) routine communication helpful [4] h) a game-like mobile app reduced self injury & suicidal behavior in young persons [20]; benefits dissipated with discontinued use i) insufficient evidence to recommend screening of patients without psychiatric disorder [10] j) USPSTF concludes that current evidence is insufficient to assess the balance of benefits & harms of screening for suicide risk in the adult population, including pregnant & postpartum women & older adults [43] k) 4 recommended practices for suicide prevention after hospital discharge: - formal safety planning - lethal-means safety planning - warm handoffs to outpatient care - follow-up with patients after discharge [47] 3) Pharmacology a) only 2 pharmaceutical agents shown to lower suicidal behavior; neither reaches therapeutic levels immediately - lithium carbonate - clozapine b) anxiolytics (benzodiazepines), sedative/hypnotics & short-acting antipsychotics may be indicated to reduce suicidal behaviors

Related

suicidal ideation (SI) suicide inhibitor

Specific

physician-assisted suicide; medical assistance in dying

General

psychiatric disease; behavioral disorder self-injurious behavior; self mutilation

References

  1. Contributions from Linda Kuribayashi MD, Dept of Medicine, UCSF Fresno
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