Continuing Education Activity

Suicide is a major public health problem not only in the United States but also in many western nations. In the United States, it is the 10th leading cause of death, accounting for nearly 44,000 deaths each year. Suicide is also the seventh leading cause of years of the potential loss of life, surpassing liver disease, diabetes, and HIV. Each year, nearly half a million individuals present to the emergency rooms in the United States following an attempted suicide. Data indicate that nearly 1 out of every 7 young adults describe having some type of suicidal ideation at some point in their lives, and at least 5% have made a suicidal attempt. Suicide has repercussions way beyond the affected individual. It costs the US healthcare system over $70 billion, and untold billions of dollars are lost by the families affected in terms of loss of earnings. Suicides are at an all-time high and affect both genders. Men are nearly 3.5 times more likely than women to commit suicide, and on average, 123 people kill themselves every day. This activity presents the causes of suicide, the risk factors, the role of medications and trigger factors, and how the medical community can counter the problem.

Objectives:

• Identify the risk factors for suicides.

• Describe the mental health disorders linked to a high risk of suicide.

• Outline medications that have been linked to an increased risk of suicide.

• Review the importance of improving care coordination amongst interprofessional team members to improve outcomes for patients at high risk for suicide.

Introduction

Suicide is a major public health problem not only in the United States but also in many western nations. In the United States, it is the 10th leading cause of death, accounting for nearly 44,000 deaths each year. Suicide is also the seventh leading cause of lost years of potential life, surpassing liver disease, diabetes, and HIV. Each year, nearly half a million individuals present to the emergency departments in the United States following attempted suicide. Data indicate that nearly 1 out of every 7 young adults admits to having some type of suicidal ideation at some point in their lives, and at least 5% have made a suicide attempt. Suicide has repercussions way beyond the affected individual. It costs the US healthcare system over $70 billion, and untold billions of dollars are lost by the families affected in terms of loss of earnings.[1][2][3]

Suicides are at an all-time high and affect both genders. Men are nearly 3.5 times more likely than women to commit suicide, and on average, 123 people kill themselves every day.

The World Health Organization (WHO) has predicted that in the next 2 years, depression will be the leading cause of disability globally. Depression is not only a North American phenomenon but is now being diagnosed in almost every nation. The annual prevalence of major depressive disorders in North America is 4.5%, but this is a gross underestimate because many individuals do not seek medical help. Depression is a serious medical disorder and associated with a high risk of suicide. Data reveals that more than 90% of individuals with a major depressive disorder see a healthcare provider within the first 12 months of the episode, and at least 45% of suicide victims have had some contact with a primary health care provider within the 4 weeks of suicide. This indicates that if their healthcare providers are more vigilant and alert, suicide is preventable in these individuals.[4]

These grim statistics have led to a National Strategy for Suicide Prevention in the United States.

Considering that many individuals who commit suicide have a mental health disorder and have visited their primary caregiver, the focus now is on health care providers becoming aware of the factors that increase the risk of suicide and refer these individuals to mental health professionals for some type of intervention. The current United States Preventive Services Task Force (USPSTF) recommendations are that primary caregivers should screen adolescents and adults for depression only when there are appropriate systems in place to ensure adequate diagnosis, treatment, and follow-up.[3][5]

Many factors have been identified in individuals who commit suicides or have attempted suicide.[6] These factors include the following:

• Advanced age
• Availability of a firearm
• Chronic illness
• A family history of suicides
• Financial difficulties
• Negative life experiences
• Loss of job
• Marital status divorced
• Medications
• Mental illnesses such as depression, anxiety, post-traumatic stress disorder (PTSD)
• Continuous pain
• A physical illness that has led to disability
• Race: white
• Gender: Male
• Social media
• Stress
• A sense of no purpose in life

Over the years, several other factors have been identified that increases the risk of suicide, and they include:

• Major childhood adverse events, for example, sexual abuse.
• Discriminated for being gay, lesbian, transgender, or bisexual
• Having access to lethal means
• A long history of being bullied
• Chronic sleep problems

• Loss of job or unemployment
• Low income
• Neurosis
• Social isolation
• Spousal loss, bereavement
• Affective disease
• Functional impairment
• Physical illness

• Traumatic brain injury
• PTSD
• Other mental health issues

The most important thing to understand is that having just one risk factor has very limited predictive value. Millions of Americans have one of these factors at any one point in time, but very few attempt suicide, and even fewer die as a result. One has to look at the entire clinical picture to increase the predictive values of these risk factors.

Function

Which type of mental health disorder is associated with an increased risk of suicide?

Accumulated data reveal that many types of mental health disorders have been associated with an increased risk of suicide, and they include the following:

• Major depression
• Schizophrenia
• Substance abuse
• Alcoholism
• Post-traumatic stress disorder
• Bipolar disorder
• Personality disorders
• Emotional stress

Medications and Suicides

Several medications have been linked to suicidal behavior, which has prompted the United States Food and Drug Administration (FDA) to require a black box warning on several prescription medications, including analgesics, anticonvulsants, and antidepressants.[7]

• Antidepressants: Several studies have shown a link between antidepressant use in childhood and teenagers to self-destructive behavior. Such an association has also been reported in adults. Thus, clinicians should be very vigilant in monitoring these patients after starting therapy.
• Anticonvulsants: Reports of suicidal behavior after initiating anticonvulsant therapy have persisted for over 2 decades. Drugs like lamotrigine, gabapentin, tiagabine, and oxcarbazepine have been linked to an increased risk for self-harm or even violent death.
• Analgesics: The analgesic tramadol has also been associated with a risk of self-harm. In 2010, the FDA added a warning to the label that the drug has the potential of causing self-harm.
• Smoking cessation medications: One of the newer anti-smoking drugs, varenicline, is also known to be associated with self-injurious behaviors and is not recommended as first-line therapy for people who want to quit smoking and have a history of mental illness.
• Glucocorticoids and anabolic steroids: It has been known for many years that both glucocorticoids and a number of anabolic steroids can induce rage and self-destructive behavior. Many professional wrestlers have committed suicide over the past 3 decades, and it is believed that this is because of anabolic steroid use.
• Individuals with bipolar disorder are at very high risk for suicidal behavior, especially females who had the onset of symptoms early in life. Several studies have shown that individuals with bipolar disorders have a high rate of attempted suicides. Besides the manic phase and impulsive behavior, these individuals can also develop severe depression that must also be considered a risk for suicide. Other comorbid factors that increase the risk of suicide in bipolar individuals include the presence of anxiety disorder and a family history of suicide. Fortunately, many international studies have shown that lithium is known to possess anti-suicidal effects in bipolar disorder. The only problem is that lithium has a very low therapeutic index, and its use has to be closely monitored. Compliance with lithium therapy is also a major issue among bipolar patients.
• Patients with schizophrenia are also at very high risk for suicide. Often these individuals experience delusions and auditory hallucinations commanding them to kill themselves. Sometimes these individuals may also become depressed because of the medications or their illness. Sometimes schizophrenia leads to severe paranoia and fear that leads one to self-harm. Finally, substance abuse, including alcohol, is common in many people with schizophrenia and may contribute to the high risk of suicide. Several studies show that the use of atypical antipsychotics in schizophrenia is associated with a decrease in suicide attempts in schizophrenia. The evidence favoring clozapine is strongest, which is, in fact, the only medication approved by the FDA for preventing suicides in these patients.
• OCD and anxiety disorders: Generalized anxiety and obsessive-compulsive disorders (OCD) can generate symptoms that may make suicide possible. Individuals with phobias can develop severe symptoms like feeling scared, frightened, or terrorized. Others may feel severe panic, anxiety, or a sense of doom. Many patients with phobics often are not able to control their behavior and may become incapacitated. Studies in college students have shown an association between OCD and suicide. The risk of suicide in OCD is increased in an individual with a substance use disorder or a comorbid personality disorder. Protective factors include female gender, educated parents, and having a comorbid anxiety disorder.
• Post-traumatic stress disorders (PTSD) can also increase the risk of suicide. Many of these survivors of physical, emotional, and sexual abuse suffer from nightmares and flashbacks. Veterans of the wars in Afghanistan and Iraq have been known to have very high rates of PTSD, with many struggling to maintain normality in everyday life. These individuals have recorded extremely high rates of suicides. Today, most veterans are screened for PTSD, and early adjustment to normal life is necessary to prevent the risk of self-harm.
• Substance abuse is known to lead to self-destructive behavior. An individual who abuses illicit agents or prescription medications can develop depression and suicidal behavior. Others may develop depression during the withdrawal period and respond by killing themselves. The latest data from the Drug Abuse Warning Network reveals that drug-related suicide attempts have increased fourfold in the past decade, averaging about 220,000 visits to the emergency room a year. Similarly, individuals who abuse alcohol or drugs may end up losing their job, spouse, and home and may respond to this situation by committing suicide.
• Even individuals in a drug recovery program are at risk for self-harm, especially those with chronic pain, those with access to a firearm and other street drugs. Many street drugs have been known to affect behavior and lead to poor psychological functioning. Suicide rates are often high in individuals who use lysergic acid diethylamide (LSD) and methamphetamine.
• Dementia and delirium often lead to memory loss, delusions, hallucinations, disorientation, and poor judgment. These symptoms frequently lead to self-harm. Many dementia patients feel that they have lost control of their minds and end up killing themselves.
• Traumatic brain injury has been associated with an increased risk of suicide. Studies in military personnel with head injuries have noted the presence of depression, PTSD, and a high risk of suicide. Repeated bouts of head injury are also associated with an even higher risk of suicide.
• Bulimia is known to be linked to a higher risk of suicide. Predisposing factors include the use of stimulants, loneliness, childhood abuse, family history of mental disorders, and difficulty interacting with people in general. Some experts believe that both a family history of suicide and genetic factors may also be high-risk factors for suicide in bulimics. Thus, when evaluating bulimics, one should try and uncover a family history of suicide[8]
• Toxoplasma infection: A large Danish study in women revealed a relationship between Toxoplasma infection and self-injury. Women who had toxoplasma infection were observed to have a high risk of self-harm than women with no serological evidence of Toxoplasma infection.[9]
• Chronic and or physical illness: A very common reason for suicide worldwide is when individuals have a chronic disease or a severe physical illness that has incapacitated them. For example, a significant number of patients with end-stage kidney disease commit suicide. Other chronic disorders that increase the risk of suicide include chronic obstructive lung disease, dementia, cancer, quadriplegia, heart failure, multiple sclerosis, and severe burns to the body. A more recent study indicates that patients with fibromyalgia and migraine also have a higher risk of suicide, and the risk is further increased in the presence of depression.
• Loss of a loved one: In some cases, acute life events may trigger suicidal behavior. This may be due to the loss of a spouse, divorce, end of an interpersonal relationship, loss of a pet, or even loss of employment. Acute loss can be agonizing and traumatic, and some people are just not able to cope with it.
• Financial instability: In the United States, financial loss or economic instability is a common cause of suicide. Over the past decade, many reports have surfaced of people who have killed not only themselves by their entire families because of financial strain. Some have lived their lives beyond their means and find no way out of the financial mess. Others may have been involved in financial fraud, and they seek suicide as a means to get out of being sentenced. Suicides due to financial loss are more common in adult men than in women. However, simply being poor or born into poverty does not increase the risk of suicide.[10]

Epidemiology

Age-Related Demographics

The risk of suicide varies by gender, age, ethnicity, and race. Suicide is known to occur in people of all ages, including high school students, but the highest rate of suicide is known to occur in seniors older than age 75.[3]

• Overall, the highest risk for suicide is in men over the age of 65.
• White males over the age of 85 have a very high rate of suicide.
• Suicide is the third leading cause of death in adolescents and teens between ages 15 to 24.
• Men have a much higher rate of suicide completion than women.
• Women tend to have a much higher rate of attempts.
• Seventy-five percent of all suicides are seen in white males.
• In men, suicide risk is highest for those between ages 50 to 85 (30 deaths per 100,000).
• In women, the suicide risk is highest between ages 60 to 65 (5 to 7 deaths per 100,000).
• Among ethnic groups, the highest risk of suicide is in Alaskan natives, American Indians, and non-Hispanic whites. While the highest risk of suicide among Alaskan natives is in adolescents, in non-white Hispanics, the risk of suicide continues to increase with advancing age.
• In the United States, the highest suicide rates are among whites, followed by American Indians and Alaskan natives. Suicide rates are much lower in African Americans, Asians, and Pacific Islanders.

Occupation-Related Demographics

Professions associated with a high rate of suicide include law enforcement and public safety officers (physicians, firefighters). These professionals often work long, irregular hours, witness all types of injuries, have exposure to guns or potent drugs, which places them at high risk for suicide. Many of these professionals use alcohol, and often the trigger is a divorce. Physicians have a particularly high rate of divorce because of job-related stress and the reluctance to seek help.[11][12][11]

One study revealed that medical residents frequently have a high rate of suicidal ideations but often do not seek help. Over the past 3 decades, suicides among military personnel have also been steadily increasing.

Seasonal Variances in Suicide

Suicides also tend to have seasonal variability, with the majority occurring during spring. The month of May is particularly notorious for having the most suicides. The general belief is that the long winter usually dampens the mood, and with the arrival of spring, some depressed people who remain depressed end their lives.

Despite the belief that year-end holidays are a frequent period of suicide, data do not support that notion. Studies show that the end-of-year holidays are usually associated with the lowest rate of suicides.

Relationship Between Suicides and Birthdays

Some people do commit suicide on their birthday. These individuals are usually males between ages 25 to 54, and irrespective of mental health history, they are known to commit suicide on their birthday. These suicides usually cannot be prevented as most males do not show up at the doctor’s office on their birthday.

Suicide in Pregnancy

Even though postpartum depression is commonly reported in women, the actual rates of suicide are rare. Suicide during pregnancy is even rarer. In any case, pregnant and postpartum females should be screened for depression.[13]

Ways of Committing Suicide

Suicide is committed in many ways, with firearms accounting for nearly 51% of cases. Other causes include using medications, jumping off buildings, hanging, jumping in front of a train, or drowning. In the United States, close to 50% of all suicides are completed with a gun. About 56% of men kill themselves with a gun, whereas only 30% of females use a gun for suicide. Other means of suicide in the United States include suffocation and poisoning.

Availability of Firearms

In the United States, the most common method of committing suicide is the use of firearms. Men are many more times likely to use a firearm compared to women. Furthermore, the risk of suicide with a firearm in men increases when the depressed individual also uses alcohol. Hence, when evaluating these individuals for suicide risk, one should determine if they own a firearm. All healthcare workers should be aware of the state statutes on possession of firearms and mental illness. Many states ban the possession of firearms by individuals with mental illness, but recent shootings in the United States indicate that many mentally ill patients continue to have access to firearms.[14]

Issues of Concern

Screening for Suicide

There has been a lot of debate on the use of universal screening for depression in primary care. However, the universal feeling is that such screening should only be undertaken if there is a strong commitment to providing treatment and follow-up. There are many screening tools for suicide, and there is no one screening tool that is applicable in all patients with a risk for suicide. Also, one should not always rely on the screening tool but also get to know the patient and the past mental health history.[15][16][17]

Targeted Screening versus Universal Screening

Many countries, including Canada, Australia, the United Kingdom, and several other European countries, have concluded that there is moderate evidence to recommend screening for depression in the primary care setting. The little evidence collected reveals that screening improves health outcomes when associated with close follow-up and treatment. However, screening alone without any follow-up is not recommended as there is inadequate evidence that it helps prevent or reduce the risk of suicide. Instead of universal screening, some experts have suggested targeted screening as is done in Wales and England. For targeted screening, the following population has been identified as a risk for suicide:

• Constant fatigue
• Elderly individuals living alone
• The home environment is impoverished.    
• Individuals with first-degree biological relatives with a history of depression
• Individual with 2 or more chronic diseases (e.g., rheumatoid arthritis, multiple sclerosis)
• Individuals with chronic pain (e.g., usually non-cancer like musculoskeletal, migraine)
• Loss of sexual interest
• Postpartum depression
• Sleep disturbances
• Socially isolated and lonely
• Substance abuse (e.g., alcohol, prescription drugs, or illicit drugs)
• Sudden changes in life (e.g., loss of a job, the death of spouse, or divorce)
• Under severe financial strain

Available Screening Tools

The USPSTF recommends the Beck Fast scan. It has seven long questions that can help determine the intensity and severity of the depression.

Suicide risk screen is a 10-item questionnaire that is often used to screen for suicide, especially in young people.

The Patient Health Questionnaire (PHQ) can also be used to identify high-risk patients. It consists of 9 items that ask various questions about self-harm.

The SAFE-T: The SAFE-T tool can be used in an outpatient setting and does offer a good insight into the extent and nature of suicidal thoughts and harmful behavior. The SAFE-T explores the following:

• What is the suicidal ideation and its intensity, frequency, and duration within the past 48 hours and over the past 4 weeks? It also determines the most serious or worst harmful thought.
• Planning of the suicide, location, time, availability, and if any preparations have been made.
• It provides information on past behaviors such as past suicide attempts and any aborted attempts.
• It also asks if the individual has rehearsed any events like loading or pointing a gun or tying a noose. Has the individual visited the location like a bridge or waterfall?
• The intent and extent when the individual is likely to carry off the plan are also assessed. The SAFE-T also gives insight into where the individual is serious or ambivalent about self-harm.

C-SSRS: The Columbia-Suicide Severity Rating Scale (C-SSRS) is another tool that is an option in outpatient settings to assess for the presence of harmful behavior. The C-SSRS also assesses any known suicide attempts and also assesses suicide ideations and behaviors. Like the SAFE-T, it can be used as an initial screen.

Cautions Regarding Screening

The sensitivity and specificity of the currently available screening tool vary from 50% to 100% and 60% to 98%. No one instrument is 100% sensitive, and choosing one depends on personal preference and experience. When initiating a screening program for suicide, it is important to have access to effective treatment and follow-up. Other considerations include:

• Making a commitment 
• Refer patients timely to consultants
• Utilize resources to prevent suicide (e.g., hotlines)
• Understand the nature of depression
• Need to administer repeat screening to identify any ongoing depression

Because not all patients complete or refuse the initial screen, the healthcare providers must be persistent in using these screening tools. Countless reports indicate that follow-up on these patients has been universally poor. Hence, the primary care provider must ensure that the patient identified with major depression is followed up. In many cases, after the initial screen is completed and support provided, patients are never rescreened again for depression. Because depression has no cure and relapse is common, rescreening should be continued at regular intervals.

The one negative about going to primary care providers for depression or any mental health disorder is that these professionals simply do not have time. They often have many other patients to deal with and can barely spare more than 15 minutes at each visit. Patients with psychosocial or emotional problems usually require much longer visits, and if they feel hurried, they will not show up again.[18]

False Positives

All healthcare workers who screen for suicide should be aware that the screening tools can lead to a false positive, which in turn can lead to high costs of medical care for the individual. This can be a severe burden for patients who do not have private insurance. A Canadian study revealed that many individuals who are suicidal have no symptoms or signs of depression. These people are very unlikely to seek assistance from healthcare providers, compared to people who are depressed.[19]

Clinical Significance

Patient History

It is important to obtain a thorough patient history, especially about thoughts and self-destructive behavior. Even though many individuals talk about suicide, they rarely follow through with it, but the opposite is true. It is established that a threat of suicide can be followed with a completed act, and the presence of suicidal ideation is closely associated with suicidal behavior.

What are Signs Suggestive of an Impending Suicide?

Over the years, experts have compiled a list of signs that may be indicative of impending suicide, and they include the following:

• Constantly talking about suicide or death: Many people planning suicide often have a plan in mind and may have made arrangements to buy a weapon.
• Individuals who indicate that they may not be around much longer. This may be by saying goodbye to family or friends, arranging a funeral plan, making a will, or writing a suicide note. The suicide note is often left in an open place and rarely hidden.
• Some of the individuals will have a strong family history of suicide. The risk of suicide is highest when one is approaching the anniversary of such a death or sometimes the age at which the family member committed suicide.
• If the individual is known to possess a weapon, especially a gun.
• Is the individual under the influence of alcohol, prescription medications, or other illicit mind-altering drugs?
• Is the individual abusing drugs like analgesics or antidepressants?
• Has there been a sudden negative event in life, like losing a job, divorce, or the death of a family member or spouse?
• Is the individual living alone, isolated, and has no support? Does he or she have any friends or family members?
• Is the individual depressed? Is he or she haunted and dominated by hopelessness and helplessness?
• Is the individual experiencing paranoia, delusions, or hallucinations telling him or her to die?
• Has the individual just been discharged from a mental health facility? Sometimes people who are discharged after a long stay in a mental health facility often have difficulty transitioning to normal life or appear to lose control because they do not feel safe.
• Is the individual anxious? Is he or she constantly worried about death or having a sense of doom and gloom? Does the individual show any emotion in the presence of others?
• Is the individual exhibiting no sensation of pleasure (anhedonia)?
• Focusing on the past. Is the person dwelling on past losses and defeats and anticipates no future? Does the person voice the notion that others and the world would be better off without them?
• Has the individual lost the ability to cope with stress? Feels that no one or nothing can help him or her?
• What is the general clinical impression? In the end, it is the clinical impression that can help determine if the patient wants to kill him or herself, and there is no other substitute for clinical judgment.

What Activities are Associated with an Intent to Commit Suicide?

Several activities that have been associated with an intent to commit suicide include the following:

• Buying a weapon like a gun, rope, or chemicals
• Getting all the house and family affairs together
• Going to the emergency room or visiting a healthcare provider
• Making a will
• Seeing friends and family unexpectedly.
• Writing a suicide note.
• Visiting a primary care physician. A significant number of people see their primary care physician within 3 weeks of committing suicide.

From an analysis of past suicide cases, it appears that a number of individuals go to the emergency department or visit their primary health care provider a few weeks before committing suicide. At this visit, they rarely mention suicidal directions but may have vague physical complaints. Thus, the healthcare provider must try to obtain a good mental health history beyond just the chief complaint.

Factors That May Protect Against Suicide

The healthcare worker should also try to ascertain protective factors against suicide such as:

• Is the individual involved in a social network of family, friends, or colleagues? Does he or she speak to them, and how often?
• Does the individual have any long-term plans? Is he looking forward to his/her job?
• Does the individual have any children, and what does he/she think about them?
• Does the individual have a pet? Often pets provide comfort and unconditional love?
• Is there a therapist involved? Individuals who remain incommunicado with therapists are less likely to have suicidal thoughts.
• Is there something in the future, like the birth of a child, graduation, wedding reception, or a vacation planned?
• Is the individual religious? In many cases, people who have faith believe in the sanctity of life.
• Does the individual have children who are dependent on him or her?
• Is the individual involved in a relationship?
• Is the individual against guns or weapons in the home?
• Is the individual calling the crisis hotlines?
• Is he or she already on treatment for depression?
• Does he or she have someone to speak to when there is a problem?

Mental Status Assessment

In some cases, assessing the mental status may provide a clue to the individual’s potential for self-harm.

• Appearance: Depressed patients will often tend to appear unclean and unkempt. The clothing may not be ironed or dirty.
• The physical exam may reveal scars or rope burns on the hands, wrist, or neck. Often these people may have multiple injuries to their body, so one has to look at the entire body for scars and marks of self-harm.
• Affect: The risk of suicide is often high in people who appear very anxious or depressed. The patient may exhibit a flat affect or no emotions at all.
• Thoughts: Individuals intent on self-harm may have several types of abnormal thoughts, which include the following:
  • Hallucinations: Some depressed patients may develop hallucinations that may be telling them to kill themselves. The majority of these hallucinations are auditory.
  • Delusions: Sometimes, an individual may develop a false belief (delusion) that everyone hates them or wants them dead. And if they die, the family will be better off.
  • Obsessions can sometimes be quite intense and can lead the individual to take his or her own life.
• Judgment, insight, and intellect: Assessing the individual’s judgment is critical. One should try and determine how the individual can handle stress. Does he or she have an impairment in decision-making? Does the individual know that jumping in front of a train is dangerous?
• Assess for memory and orientation, which are often abnormal in patients with self-destructive behaviors.

It is vital that the healthcare professional not only rely on the screening tools to identify patients at risk for suicide. It is important to conduct a patient interview at the same time to reflect the following:

• Reflect empathy and concern
• Offer a hand to help.
• Understand the individual’s desire to die to relieve excruciating pain, severe mental anguish, or major depression
• Provide the patient with confidence that he or she can overcome the issues
• Determine why the patient has come to the stage of wanting to kill him or herself

Management

Immediate Treatment

Once the patient is deemed to be at risk for suicide, intervention steps must commence right away.[20] These include the following:

• The individual must not be left alone.
• All weapons or instruments that can be used to harm or hurt must be removed. If the weapons are not removed, they should be locked in a cabinet. One may even want to disable the gun.
• Enlist the help of a support person while at home.
• The suicidal individual must be treated in a safe and secure place. Also, the place has to be monitored.
• In-patient care is an ideal place for patients intent on committing suicide, but this is only possible for extremely high-risk cases. Admitting all patients that are at risk for suicide is not realistic or practical.

If the patient is sent home, then the following additional safety measures must be established:

• Help develop internal coping strategies (e.g., exercise, journaling, reading, developing a  hobby).
• Promote social support. Call a family member, social worker, or friend to check up on the individual. 
• Utilize the help of healthcare professionals to follow up on therapy.
• Provide the individual with the National Suicide Prevention Lifeline.
• Tell the individual to call 911 if he or she develops the desire to die.
• As a last resort, tell family members to bring the individual to the emergency department if there is decompensation at home.

Once the individual is safe as an inpatient or outpatient, a formal treatment plan should be established. The next step is to refer all patients deemed to be at higher risk for suicide to a mental health counselor as soon as possible. Every state has laws and procedures regarding this process which must be incorporated into the clinical practice when addressing individuals at high suicide risk.

Pharmacologic Therapy

If the individual has acute psychiatric symptoms like paranoia, hallucinations, extreme anxiety, or depression, pharmacological therapy may be necessary. After the patient’s acute symptoms have been managed, the choice of further treatment depends on the specific mental illness. In most cases, psychotherapy is recommended to remove the thoughts about self-harm. However, it is important to note that despite these interventions, many patients do commit suicide. Hence it is important to involve the patient’s family, friends, and social worker in the long-term management of these patients.[21][22][23]

Psychotherapy

While drug treatment is useful for managing acute symptoms like hallucinations, psychosis, or depression, psychotherapy is essential for long-term management. Cognitive behavior therapy and other related therapies like problem-solving therapy, dialectical behavior therapy, and developmental group therapy have all been used to lower the risk of suicide. A psychiatrist or psychotherapist usually administers these treatments. The problem is that these therapies require regular sessions spread over many months or even years. The other problem is the cost which can be high for those not covered by medical insurance.[24]

Moving Beyond Screening

Some experts suggest an alternative approach to preventing suicide other than identifying individuals at risk. The reason is that the present medical model of screening has not been shown to be effective in suicide prevention. Suicide has been strongly linked to social problems. The rates are generally much higher in local communities that lack a cohesive social fabric or when individuals are left out of mainstream society. Thus, the social factors should be targeted like improving housing, providing opportunities for jobs, making it easy to access mental health care professionals and prescription medications. Unfortunately, many social factors go way beyond the ability of most primary health care providers to manage. Plus, there is also a significant cost that comes with making changes in the social structure.

What is an Effective Follow-up?

Experts say that if a screening program for suicide prevention and depression is to be started, there must be effective follow-up and treatment. Once an individual has been diagnosed with depression and is at high risk for suicide, then there must be a system in place for treatments such as psychotherapy and/or antidepressant medications. If close follow-up and treatment are not available, the clinician can recommend a referral and follow-up. 

Is There Evidence that Screening for Suicide Can Improve Outcomes?

Evidence shows that when the screening tools are used appropriately, there can be useful in helping healthcare workers recognize depression. When a commitment to follow-up and treatment accompanies the screening tools, better outcomes are achieved. However, screening tools are only to be used by healthcare workers committed to using the information from the screening test and providing enhanced care. The current evidence on screening for suicide risk in primary care is insufficient, and the balance of benefits and harms of screening cannot be determined.[25] 

At the moment, there is little evidence to support screening the population at large. In fact, in people without any psychiatric history, the role of screening remains debatable. Thus, healthcare workers are being urged to first identify patients with risk factors for suicide and those with high levels of mental stress and refer them for further evaluation. So far, each hospital or organization has its protocols for the use of suicide prevention tools. No study has ever shown that one tool is better than the other.

Other Issues

Screening for Suicide Risk Summary of the Recommendations[5]

Population

Adolescents, adults, and older individuals who do not have an identified psychiatric disorder do not need a screen. The indication to screen depends on the presenting and past clinical history.

Risk Assessment

Since the suicide risk varies by gender, age, and race/ethnicity, some populations need careful screening, for example, older white males.

Assess for presence of:

• Mental health disorder
• Serious adverse childhood events
• A family history of suicide
• Prejudice or discrimination associated with being lesbian, gay, bisexual, or transgender
• Access to lethal means
• Possibly a history of being bullied
• Sleep disturbances
• Chronic medical conditions 

In men, assess socioeconomic factors, such as low income, occupation, and unemployment.

In older adults, additional risk factors include social isolation, spousal bereavement, neurosis, affective disorders, physical illness, and functional impairment.

Risk factors of importance to military veterans include traumatic brain injury, separation from service within 12 months, posttraumatic stress disorder, and mental health conditions.

It is important to understand that one single risk factor has very little predictive value, and hence, one should look at the entire picture. Many Americans have one risk factor for suicide at any point in their lives, but very few will attempt suicide, and even fewer will die from it.

Screening Tests

The choice of screen tests is a matter of personal preference because they all have a broad range of accuracy. Data on predictive values of the screening tests are limited.

Treatment

Once a patient is deemed to be at risk for self-harm, referral to a mental health professional is recommended. The key treatment to reduce the risk of suicide is psychotherapy, which includes cognitive behavior therapy (e.g., dialectical behavior therapy, problem-solving therapy, and developmental group therapy).

Enhancing Healthcare Team Outcomes

Can Screening for a Suicide Lead to Harm?

To date, there is insufficient to determine for screening for suicide leads to harm to the individual or society as a whole. Presently, the USPSTF has concluded that the evidence for suicide screening in primary care/nursing is inadequate and that the balance between harm or benefit cannot be determined.

The costs of screening for suicide are minimal. Except for some time and the use of questionnaires, there are no other exorbitant costs. The latest data reveals that less than 20% of primary care physicians screen adolescents or seniors for suicidal risk factors. All interprofessional healthcare team members, including clinicians, nurses, pharmacists, therapists, and auxiliary personnel, should be alert to signs of possible suicide, and those with more clinical training can initiate the screening process. This =team approach can help prevent suicide attempts. [Level 5]

Suicide Resources

• Before discharging patients with depression, anxiety, or suicidal ideations, it is important to prove them with resources and referrals.[26]
• The National Suicide Prevention Lifeline can be reached at 1-800-273-TALK (8255); this site operates 24/7 and has trained counselors available at all times.
• The patient should be asked to contact the US Substance Abuse and Mental health Services administration online and ask for FREE wallet cards which provide information about the National Suicide Prevention Lifeline.
• The Friendship Line is free and available to people over the age of 60. It operates 24/7 and can be reached at 1-800-971-0016. The Friendship Line assists seniors who feel lonely, depressed, or are contemplating suicide.
• Finally, the patient should receive the names of local mental health care professionals they can reach in case of an emergency.

An integrated and collaborative interprofessional team approach is necessary to identify those at the highest risk of suicide and appropriately manage their risk. The clinical nurse or psychiatry-trained nurse can assist the medical team by screening patients for suicide risk using validated screening tools. Communicating these findings with the clinicians can help patients receive appropriate medical and social support to decrease their risk. The community nurse, specialty-trained social worker, and case manager can help monitor and follow up on those identified at the highest risk of suicide to ensure they follow up with the treatment plan advised and that their needs outside of medical therapy are met. Nurses also assist the clinicians by educating the patients on suicide prevention aids and resources to seek the help they need if and when necessary. A multifaceted interprofessional team approach can reduce the number of suicide-related deaths without overburdening the current healthcare system. [Level 5] 

Nursing, Allied Health, and Interprofessional Team Interventions

When a patient presents to the emergency setting and is suicidal and cannot contract for safety, they will need to be medically cleared and watched until evaluated by appropriate mental health services.