Suicidal behavior

Suicidal behavior includes 3 types of suicidal actions: completed suicide, suicide attempts, suicidal gestures (actions). Thoughts and plans about suicide are described as suicidal ideation.

A completed suicide is a suicidal act that results in death. A suicide attempt is an act intended to commit suicide but that does not result in death. Often, suicide attempts involve at least some ambivalence about wanting to die and may be a cry for help. Suicidal gestures (acts) are attempts with very little lethal potential (e.g., superficial cuts to the wrists, overdosing on vitamins). Suicidal gestures and suicidal ideation are most often requests for help from people who still want to live. They are the primary means of communicating feelings of despair and hopelessness. However, they are quite difficult to free oneself from.

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Epidemiology of suicidal behavior

Statistics on suicidal behavior are based primarily on death certificates and coroner's reports and underestimate the true prevalence. Suicide is the 11th leading cause of death in the United States, with 30,622 completed suicides in 2001. It is the third leading cause of death among people aged 15 to 24. Men aged 75 and older have the highest rate of death by suicide. Of all age groups, men commit suicide more often than women by a ratio of 4:1.

It is estimated that over 700,000 people attempt suicide each year. For every suicide death, there are about 25 suicide attempts. However, about 10% of people who attempt suicide actually commit suicide because many people attempt suicide more than once. About 20-30% of people who attempt suicide do so again within a year. About three women attempt suicide for every man who does so. The rate of suicide attempts is disproportionately high among teenage girls. Suicides run in families.

People in strong relationships have a significantly lower risk of suicide than single people. Rates of suicide attempts and completed suicides are higher among those living alone. Suicide is less common among members of most religious groups (especially Catholics).

Group suicides, whether involving many people or just 2 (such as lovers or spouses), represent an extreme form of personal identification with other people.

About 1 in 6 people who commit suicide leave a suicide note. The content may reveal the mental disorder that led to the suicide.

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Causes of suicidal behavior

The major treatable risk factor is depression. Other factors include social factors (disappointment and loss) and personality disorders (impulsivity and aggression). Traumatic experiences in childhood, especially the stress of a broken home, parental deprivation, and abuse, are significantly more common among people who commit suicide. Suicide is sometimes the final act in a chain of self-destructive behaviors such as alcoholism, reckless driving, violent and antisocial behavior. Often, one factor (usually the breakdown of an important relationship) is the last straw. Severe physical illness, especially chronic and painful illnesses, plays a major role in about 20% of suicides among older people.

Alcohol and substance abuse can increase disinhibition and impulsivity, as well as worsen mood; a potentially lethal combination. About 30% of people who attempt suicide drink alcohol before the attempt, and about 1/2of them were in a state of intoxication at that moment. Alcoholics are prone to suicide, even if they do not drink.

Some patients with schizophrenia commit suicide, sometimes because of depression, to which these patients are prone. The method of suicide may be bizarre and violent. Suicide attempts are not common, although they may be the first sign of mental disorder occurring early in schizophrenia.

People with personality disorders are prone to suicidal attempts, especially emotionally immature people with borderline or antisocial personality disorder, because they have poor frustration tolerance and respond to stress impulsively, with violence and aggression.

Aggression toward others is sometimes evident in suicidal behavior. In rare cases, former lovers or spouses are involved in a murder-suicide, in which one person kills another and then commits suicide.

Risk factors and warning signs of suicide

• Personal and social factors
• Male gender
• Age >65 years
• Previous suicide attempts
• Making a detailed suicide plan, taking steps to implement the plan (acquiring weapons, medications), precautions against disclosure of the plan
• Personally significant anniversaries
• Presence of suicide or affective disorders in the family
• Unemployment or financial difficulties, especially if they result in a marked decline in economic status
• Recent separation, divorce or widowhood
• Social isolation with real or imagined bad treatment from relatives or friends

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Symptoms of suicidal behavior

• Depressive disorders, especially at the beginning or towards the end of the disease
• Marked motor agitation, restlessness and anxiety with marked insomnia
• Marked feelings of guilt, hopelessness; ideas of self-blame or nihilistic delusions
• Delusional or near-delusional ideas of somatic illness (e.g., cancer, heart disease, sexually transmitted diseases)
• Imperative hallucinations
• Impulsive, unfriendly personality
• Alcohol or substance abuse, especially recent onset
• Chronic, painful or disabling medical conditions, especially in previously healthy patients

The use of medications that may contribute to suicidal behaviour (for example, sudden discontinuation of paroxetine and some other antidepressants may lead to an increase in anxiety and depression, which in turn increases the risk of suicidal behaviour) disorders, especially depression, are often a risk factor for suicide, recognition of these possible factors and initiation of appropriate treatment are an important contribution that the general practitioner can make to the prevention of suicide.

Every depressed patient should be asked about suicidal ideation. Concerns that such questions will encourage the patient to self-harm are unfounded. Questioning will help the physician obtain a clearer picture of the depth of the depression, support constructive discussion, and convey the physician's awareness of the depth of the patient's despair and hopelessness.

The risk of suicide increases early in the treatment of depression, when psychomotor retardation and indecisiveness are reduced and depressed mood is only partially improved. Therefore, psychoactive drugs should be carefully selected and prescribed in nonlethal quantities so that consuming the entire contents of the prescribed package does not result in death. There is some evidence that some antidepressants increase the risk of suicidal behavior, especially in adolescents. Patients should be warned when they start taking antidepressants that their condition may initially worsen and instructed to call their doctor if their condition worsens.

Even people who threaten imminent suicide (e.g., patients who call and declare their intention to take a lethal dose of drugs or when threatening to jump from a height) may retain some will to live. The physician or any other person to whom the suicidal patient turns for help should support the patient's will to live. Emergency psychiatric care consists of establishing contact and open communication with the person; reminding him of his identity (i.e., periodically repeating his name); helping him sort out the problems that caused the crisis; offering constructive help in solving these problems; supporting him in positive actions; reminding him of the caring and helpful desire of his family and friends.

Methods of choosing suicide

The choice of methods is determined by cultural factors and availability, as well as by the seriousness of intent. Some methods (e.g. jumping from a height) make survival virtually impossible, while others (e.g. taking drugs) retain the possibility of survival. However, the use of methods that are not fatal does not necessarily mean that the intent was less serious. Bizarre, bizarre methods of suicide indicate an underlying psychosis. Drug overdose is the most common method of suicide attempts. Methods that involve violent means, such as firearms and hanging, are rarely used in suicide attempts. Some methods, such as driving a car off a cliff, may endanger the lives of others. Police-assisted suicide is an unusual form of suicide in which a person commits an act (e.g. brandishing a weapon) that forces a police officer to kill him or her.

Assisted suicide

Assisted suicide refers to situations in which a physician or other professional provides some assistance to a person wishing to end their life. Assistance may include prescribing medications that can be stockpiled for a lethal dose, advising on a painless method of suicide, or administering a lethal dose of medication. Assisted suicide is controversial and illegal in most states in the United States. However, patients with painful, debilitating, and incurable conditions may engage in discussions with their physicians about it. Assisted suicide may raise difficult ethical questions for physicians.

Suicide Management

A health care professional who becomes aware that a patient is contemplating suicide must, in most legal systems, inform the appropriate authorities for intervention. Failure to do so may result in criminal and civil consequences. Such patients should not be left alone until they are in a safe environment. Transport to mental health facilities should be accompanied by trained professionals (e.g., ambulance, police), not family or friends.

Any suicidal act, whether attempted or actual, must be taken seriously. Anyone who seriously injures themselves should be assessed and treated for physical injury. If an overdose of a potentially lethal drug is confirmed, immediate action should be taken to prevent absorption and accelerate excretion, administer an antidote if available, and provide supportive care (see Chapter 326 on page 3464).

The initial assessment should be carried out by someone specially trained in the assessment and treatment of suicidal behaviour. However, psychiatric assessment should be carried out as soon as possible on all patients. A decision should be made as to whether the patient requires hospitalisation, involuntary or restraining measures. Patients with psychotic disorders, delirium, epilepsy, some with severe depression and those in an unresolved crisis should be admitted to a psychiatric unit.

Following a suicide attempt, the patient may deny any problems, as the severe depression that led to suicidal actions may be followed by a short period of elevated mood. However, the risk of committing suicide later remains high, despite the resolution of the patient's problems.

A psychiatric assessment identifies some of the issues that are important in the suicide attempt and helps the physician plan appropriate treatment. It consists of establishing rapport; understanding the suicide attempt, its background, antecedents, and the circumstances in which it was undertaken; understanding the difficulties and problems involved; carefully considering the personal and family relationships that are often relevant to the suicide attempt; fully assessing the patient's mental state, with particular emphasis on recognizing depression, anxiety, agitation, panic attacks, severe insomnia, or other psychiatric disorders and substance abuse that require specific treatment in addition to crisis intervention; communicating with close family members and friends; and contacting the family physician.

Suicide prevention

Prevention requires identifying people at risk of suicide and initiating appropriate interventions.

Although some suicide attempts and completed suicides are highly unexpected, even to close relatives and colleagues, clear hints about impending action may be given to family members, friends, or health care professionals. These messages are often overt, such as discussing plans or suddenly writing or changing a will. However, warnings may be less overt, such as comments about the emptiness of life or that it would be better if he died.

On average, a primary care physician sees 6 or more suicidal patients each year. About 77% of people who commit suicide had been seen by a physician in the year before their suicide, and about 32% had been under psychiatric care in the previous year. Because severe, painful medical illnesses, substance abuse, and mental disorders

The Suicide Effect

Any suicidal act has a profound emotional impact on everyone involved. The physician, family, and friends may feel guilt, shame, remorse for not having been able to prevent the suicide, and anger toward the suicide or others. The physician can be a valuable resource for helping the family and friends of the deceased cope with their feelings of guilt and regret.