Basics
Description
- The intentional taking of ones own life
- Suicidal ideation:
- Passive: A conscious desire not to live
- Active: Intention to die with or without a plan
- Parasuicidal behavior: Self-injury not intended to cause death (e.g., superficial cutting, cigarette burns, head banging)
- Reckless behavior: Not taking prescribed medications, taking too much of prescribed medications, running into traffic
- Risk-to-rescue ratio " ”lethality of plan compared with likelihood of rescue:
- High risk-to-rescue ratio indicates increased severity of attempt.
- Occult presentation:
- Many individuals at risk for suicidal behavior seek care in the ED for nonbehavioral complaints
- Improved suicide screening practices may be needed to capture this population.
Etiology
- 36,891 suicides in US (CDC 2009)
- 12 " “25 attempts per every completed suicide
- 25.4 per 100,000 males (CDC 2009)
- 7.4 per 100,000 females
- 11.1 per 100,000 general population
- 2 peaks in age group most at risk for suicide:
- Age 15 " “24 yr (3rd leading cause of death in this age group)
- Age >60 yr (highest rates of any age group, increasing incidence with age)
Risk Factors for Suicidal Behavior
- Depression (bipolar or unipolar)
- Alcohol or drug abuse
- History of physical or sexual abuse
- Unemployment
- Incarceration
- History of head injury or neurologic disorder
- Firearms in the home
- Cigarette smoking
- Positive family history of suicide attempt
- Psychiatric or medical comorbidities
- Gender:
- Women 3 times more likely to attempt suicide.
- Men 3 times more likely to complete suicide.
- Psychological:
- Impulsivity/aggression
- Depression
- Anxiety
- Hopelessness
- Self-consciousness/social disengagement
- Poor problem-solving abilities
- Lack of social supports
- Widowed
- Divorced
- Separated
- Lack of social supports
- Recent loss of relationship
- Anniversary of loss
- Environmental
- Rural areas:
- Access to firearms
- Poverty
- Unemployment
Risk Factors for Completed Suicide
- Male
- Age >60 yr
- White or Native American
- Widowed/divorced
- Living alone
- Unemployment/poverty
- Past suicide attempt
Methods of Suicide (CDC 2009)
- Firearms (most common among men and 2nd most common in women)
- Overdose (Most common among women); most common means of suicide attempt (70% of failed attempts are by overdose)
- Hanging
- Suffocation
Populations at Highest Risk for Completing Suicide
- >90% of patients who commit suicide have a psychiatric diagnosis.
- Depression " ”especially psychotic depression
- Anxiety and panic disorder
- Alcohol or drug intoxication
- Schizophrenia
- Adolescents
Others at Risk for Completing Suicide
- Recent discharge from psychiatric facility
- History of suicidal ideation or suicide attempt
- Serious physical illness present in up to 70% of all suicides, particularly in elderly patients.
- History of incarceration
- Physicians
- Victims of violence/abuse
Interventions that Lower Risk
- Patients with mood disorders (major depression and bipolar disorder) treated with lithium
- Patient with major depression treated with electroconvulsive therapy
- Patients with schizophrenia treated with clozapine
- NOT shown to decrease suicide rates: Treatment with selective serotonin reuptake inhibitors (SSRIs) for major depression
Protective factors
- Strong social supports
- Family cohesion
- Peer group affiliation
- Good coping and problem-solving skills
- Positive values and beliefs
- Ability to seek and access help
Diagnosis
Signs and Symptoms
- Depressed mood
- Verbalization of suicidal ideation with or without plan
- Hopelessness
- Helplessness
- Anger/aggression
- Impulsivity
- Psychotic symptoms (i.e., paranoia, command auditory hallucinations)
History
- Obtain history to assess risk:
- Asking about suicide does not increase risk for attempt
- Degree of suicidal ideation
- Plan immediate risk of self-injury?
- Means available to complete plan
- Activity toward initiating plan
- Patients expectations of lethality of plan
- Intent: Reasons, goal
- Risk-to-rescue ratio
- Plan or intent to harm others?
- Presence of acute precipitants:
- Recent losses, lack of social supports
- Risk factors:
- History of past suicide attempts
- Psychiatric review of symptoms: Depression, psychosis, panic/anxiety
- Chronic medical illness
- Alcohol or drug abuse
- Serial assessment of mental status, consistency of responses
- Factors preventing suicide
Physical Exam
- As needed to address acute medical issues
- Look for evidence of injuries and signs of self-neglect.
Scoring Systems
- Modified SAD PERSONS Score:
- Sex: Male 1 point
- Age <19 or >45 yr 1 point
- Depression or hopelessness 2 points
- Previous attempts or psychiatric care 1 point
- Excessive alcohol or drug use 1 point
- Rational thinking loss 2 points
- Separated/divorced/widowed 1 point
- Organized or serious attempt 2 points
- No social supports 1 point
- Stated future intent 2 points
- Data suggests that patients with a score of <5 can safely be managed as an outpatient
Essential Workup
- Collateral information from outpatient care givers, family, friends
- Safety plan:
- Would the patient immediately seek help if suicidal ideation recurred?
- Elimination of means of suicide
- Access to other means of suicide
- Support and supervision in the outpatient setting
- Prompt outpatient follow-up with psychiatric therapy
- Patient investment in not attempting suicide
- Identifying reasons for living
- Safety contracts are no guarantee that individuals will not attempt suicide.
Diagnosis Tests & Interpretation
Lab
- Blood " “alcohol level
- Serum toxicology screen: Aspirin, acetaminophen, and other medications
- Urine drug screen:
- Many psychiatric facilities require toxicology screen before placement.
- Carbon monoxide (as indicated)
Imaging
Not routinely indicated ‚
Diagnostic Procedures/Surgery
ECG " “ as indicated ‚
Differential Diagnosis
- Normal despondency
- Bereavement
- Adjustment disorder with depressed mood
- Major depressive disorder
- Bipolar disorder
- Organic mental disorder (head injury, dementia, delirium)
- Schizophrenia
- Panic and anxiety disorders
- Alcohol or drug abuse
- Borderline personality disorder
- Antisocial personality disorder
- Accidental death
- Attempted homicide
- Suicide is a leading cause of death among young people 15 " “24 yr of age.
- More than 4,000 adolescents commit suicide every year (CDC 2009)
- Rapidly increasing in young black males ages 10 " “14 yr
- Less evidence available to link suicide in youth to overt psychiatric illness
- Stresses:
- Prior attempts
- Family disruption
- History of psychiatric disorder
- Depression
- Disciplinary crisis
- Broken romance
- School difficulties
- Bereavement
- Rejection
- History of physical or sexual abuse
- Early warning signs:
- Progressive declining schoolwork
- Multiple physical complaints
- Substance abuse
- Disrupted family relations
- Social withdrawal
- Anhedonia
- Suicide rates highest in age >65 yr
- Completed suicide: 83% men
- Risk factors: Divorced, widowed, male, social isolation
- Tend to use more lethal methods
- Lower ratio of attempts to completions
Treatment
Pre-Hospital
- For potentially dangerous patient who refuses transport to treatment facility; involve police and impose restraint.
- Risk to medics on the scene in cases of firearms or other weapons
- Know state and local laws, availability of mobile crisis units, and when to involve the police.
Initial Stabilization/Therapy
- Prevent ability to elope
- Ensure patient safety:
- Remove sharp objects, belts, shoelaces, and other articles that could be used for self-injury
- Provide safe environment
- Appropriate supervision
Ed Treatment/Procedures
- Confer with patients outpatient therapist or physician if possible
- Voluntary admission to psychiatric facility
- Involuntary admission if patient refuses voluntary
- For involuntary psychiatric admission, patient must have psychiatric disorder and 1 of the following:
- Risk for danger to self
- Risk for danger to others
- Inability to care for self
Medication
Treat underlying psychiatric disorder. ‚
Follow-Up
Disposition
Admission Criteria
- If patient endorses suicidal ideation with plan and intent, admission may be needed for safety.
- If impulsivity, anger, or aggression hinder ability to control behavior
Discharge Criteria
- Patient has no suicidal ideation.
- Patient agrees to return to ED immediately or seek psychiatric help if suicidal ideation recurs.
- Patient has passive suicidal ideation without plan or intent.
- Patient has good support network or placement in appropriate crisis housing
- Appropriate outpatient psychiatric follow-up is ensured.
- In some cases, patients who express suicidal ideation while intoxicated may be discharged if no longer suicidal once they are sober.
- Some patients with borderline personality disorder and chronic suicidal ideation are discharged after careful psychiatric evaluation in consultation with long-term outpatient caregivers.
Followup Recommendations
Close psychiatric follow-up for those with acute illness who do not require admission ‚
Pearls and Pitfalls
- A careful history will identify risk factors for suicide.
- Access collateral sources of information about patients recent thoughts and behavior.
- Maintain patient safety during evaluation
- Hospital admission may be required if patient endorses suicidal ideation and plan.
Additional Reading
- Ali ‚ A, Hassiotis ‚ A. Deliberate self harm and assessing suicidal risk. Br J Hosp Med (Lond). 2006;67(11):M212 " “M213.
- Cooper ‚ JB, Lawlor ‚ MP, Hiroeh ‚ U, et al. Factors that influence emergency department doctors ' assessment of suicide risk in deliberate self-harm patients. Eur J Emerg Med. 2003;10(4):283 " “287.
- Miller ‚ M, Hemenway ‚ D. The relationship between firearms and suicide: A review of the literature. Clin Neurosci Res. 2001;1:310 " “323.
- Nock ‚ MK, Borges ‚ G, Bromet ‚ EJ, et al. Suicide and suicidal behavior. Epidemiol Rev. 2008;30:133 " “154.
- Ronquillo ‚ L, Minassian ‚ A, Vilke ‚ GM, et al. Literature-based recommendations for suicide assessment in the emergency department: A review. J Emerg Med. 2012;43(5):836 " “842.
- Ting ‚ SA, Sullivan ‚ AF, Miller ‚ I, et al. Multicenter study of predictors of suicide screening in emergency departments. Acad Emerg Med. 2012;19(2):239 " “243.
See Also (Topic, Algorithm, Electronic Media Element)
Depression ‚
Codes
ICD9
- 311 Depressive disorder, not elsewhere classified
- V17.0 Family history of psychiatric condition
- V62.84 Suicidal ideation
- 300.9 Unspecified nonpsychotic mental disorder
ICD10
- R45.851 Suicidal ideations
- Z81.8 Family history of other mental and behavioral disorders
- Z91.5 Personal history of self-harm
- F32.9 Major depressive disorder, single episode, unspecified
- T14.91 Suicide attempt
SNOMED
- 267073005 Suicidal (finding)
- 247650009 Planning suicide (finding)
- 425104003 suicidal behavior (finding)
- 160333008 Family history: Suicide (situation)
- 161474000 History of attempted suicide (situation)
- 304594002 Suicidal intent (finding)
- 35489007 Depressive disorder (disorder)