Continuing Education Activity

Suicide is the tenth most common cause of death in the United States, but it can often be prevented with appropriate intervention. This activity reviews how to identify persons at risk for suicide, questions that health professionals must ask at-risk patients, and management protocols for suicidal patients. This activity addresses the role of the interprofessional team in the care of suicidal patients.

Objectives:

• Identify the key risk factors for suicide.

• Summarize the evaluation of a patient for suicidal ideation.

• Explain how to manage a suicidal patient.

• Review the role of the interprofessional team in identifying and caring for suicidal patients.

Introduction

Suicide is one of the most important events that health professionals must address. The clinical assessment and subsequent intervention become critical in the optimization of life in the setting of suicidality. Remember that suicide constitutes a permanent solution to a temporary problem. This article outlines critical statistics and risk factors so clinicians can recognize the individuals requiring special intervention, identifies the major questions to ask a potentially suicidal individual, details the actual steps to ensure the patient’s safety, and concludes steps that should be addressed with the family and friends in the case of completed suicide.[1][2][3][4][5]

Etiology

A number of factors increase the diathesis of 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 patient’s self-destructive path but also help the clinician determine the appropriate treatment for the patient. Once the patient is safe, then the underlying dynamics can be addressed.

Epidemiology

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.

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. 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.[6]

Pathophysiology

Low cerebrospinal fluid (CSF) concentrations of 5-HIAA have been found in violent suicide attempters and suicide victims.[7] CSF 5-HIAA concentrations have both genetic and environmental determinants. 5-HIAA is a serotonin metabolite. Patients with fatal suicides have low 5-HIAA. Low concentrations of 5-HIAA in the cerebrospinal fluid reliably are present in patients exhibiting suicidal behavior.

History and Physical

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, a threat of suicide can lead to the completed act; therefore, suicidal ideation should not be dismissed cavalierly, as research suggests associations between suicidal ideation and attempts.[8][9][10][11]

Numerous activities are associated with completing 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.

Evaluation

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 their patient is going to commit suicide. The clinician's reaction counts and should be considered in the intervention.[12][13][14][15]

Suicidal Ideation

Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is associated with suicidal behavior. 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 the reason for concern, responses indicating that the person has purchased a gun or ammunition, made out a will, and plans to use the gun are more dangerous. The plan demands further questions. If the person envisions a gun-related death, determine whether they have 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 had 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 shows that suicidal thoughts can serve as an indicator of suicidal plans and attempts.

Purpose of Suicide

Determine what the patient believes their 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 a relief from their 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. 

A mixed-methods study in the UK analyzed 60 homicide-suicides and found that most victims were spouses/partners and/or children. Most perpetrators were male (88%), and most victims were female (77%). Few perpetrators had been in recent contact with mental health services before the incident (12%).

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.

Treatment / Management

Intervention

The treatment of a suicidal patient involves a 2-phase process. First and foremost, the patient’s 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.[16][17][18][19][20]

First Phase

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) was associated with significant reductions in the overall psychiatric inpatient suicide rate and the rate of inpatient suicide by hanging. 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. This study points out the need to pay attention to the number of stockpiled medications available to potentially self-destructive patients.

Second Phase

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.

Differential Diagnosis

• Alcoholism

• Anxiety disorders

• Bipolar disorder

• Delirium

• Depression

• Personality disorders

• Posttraumatic stress disorders

• Schizophrenia

Prognosis

It would be a tautology to exhort that the prognosis of suicide is grim, as suicide entails the termination of life. However, regarding suicidal ideation, studies suggest that a third progress to making 'plans.' Of those with ideation and a plan, 55% will attempt suicide, whereas those with only ideation have a 15% chance of making an attempt. This transition from ideation to planning to attempt is thought to transpire within a year of the manifestation of the suicidal impulses.

Complications

One would expect that intense intervention efforts following a suicide attempt would be effective in lowering morbidity and mortality. To test this theory, Morthorst et al. assessed the efficacy of the outpatient intervention in patients older than 12 years admitted to regional hospitals in Copenhagen with a suicide attempt within the past 14 days. The intervention consisted of assertive outreach that provided crisis intervention and flexible problem-solving. This approach, an assertive intervention for deliberate self-harm, incorporated motivational support and actively assisted patients in 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 intensive follow-up care, it does point out the need for a clear, definite, and defined post-suicide attempt treatment plan.

Deterrence and Patient Education

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.

Pearls and Other Issues

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.

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 the 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.

Enhancing Healthcare Team Outcomes

The only way to prevent suicides is to work in an interprofessional team that includes a mental health nurse, psychiatrist, primary care provider, social worker, and nurse practitioner. Practitioners must work with the patient's family and friends, as well as with the other patients who knew the deceased. The first step is to prevent harm to the patient and, secondly, treat the cause of the behavior that is causing suicidal ideations. All patients with suicidal ideations should be closely monitored. The family should be educated about the potential signs of danger. Unfortunately, in many cases, the healthcare system does fail, as many patients go on to end their lives.[21] [Level 5]