Suicide, or intentional self-harm with the intent of causing death, is the eleventh leading cause of death in the United States, accounting for more than 30,000 deaths each year.¹ Nonlethal self-inflicted injuries are even more prevalent, accounting for more than 500,000 emergency department visits per year² and reflecting the high ratio of suicide attempts to completed suicides. Psychiatric disorders are associated with more than 90% of completed suicides^3,⁴ and with the majority of attempted suicides.⁵^–⁷ Therefore, psychiatrists must be familiar with the evaluation and treatment of patients who contemplate, threaten, or attempt suicide. Although guided by knowledge of epidemiological risk factors for suicide (Table 53-1), the clinician must rely on a detailed examination and on clinical judgment in the evaluation of current suicide risk.

Table 53-1 Risk Factors for Suicide

Psychiatric illness
• Major depression • Bipolar disorder • Alcoholism and drug dependence • Schizophrenia • Character disorders • Organic brain syndrome • Panic disorder

Race

Marital status (widowed, divorced, or separated)

Living alone

Recent personal loss

Unemployment

Financial/legal difficulties

Co-morbid medical illness (having chronic illness, pain, or terminal illness)

History of suicide attempts or threats

Male gender

Advancing age

Family history of suicide

Recent hospital discharge

Firearms in the household

Hopelessness

EPIDEMIOLOGY AND RISK FACTORS

Epidemiology

Suicide accounts for 1.3% of the total number of deaths in the United States each year.^1,⁸ For every person who completes suicide, approximately 8 to 10 people attempt suicide.^9,¹⁰ Although no nationwide data on annual attempted suicides are available, research indicates that for every completed suicide, approximately 8 to 25 attempts are made¹¹^–¹³; that is, some individuals make more than one unsuccessful attempt. Each year, emergency departments treat approximately 500,000 suicide attempters.^14,¹⁵ These visits represent approximately 0.5% of all annual emergency department visits.^2,¹⁴

Use of firearms is the most common method of committing suicide for both men and women in the United States, accounting for between 50% and 60% of annual suicides.^12,¹³ Suffocation, including hanging, is the second most common cause of suicide overall in the United States, and the second most common cause in men, accounting for approximately 6,500 suicide deaths per year.^15,¹⁶ Poisoning, including drug ingestion, is the third most common cause of completed suicide in the United States and the second most common cause in women, accounting for approximately 5,500 deaths per year.^15,¹⁶ Historically, drug ingestion has accounted for the majority of unsuccessful suicide attempts.^17,¹⁸

Suicide rates differ by age, gender, and race. Rates generally increase with age; people older than age 65 are 1.5 times more likely to commit suicide than are younger individuals, while white men over age 85 have an even higher rate of suicide.^14,^19,²⁰ The number of suicides in the elderly is disproportionately high; the elderly appear to make more serious attempts on their lives and are less apt to survive when medical complications from an attempt ensue—one out of four attempts in this group results in a completed suicide.¹⁹^–²¹ Although the elderly have the highest suicide rates, suicide in young adults (between ages 15 and 24) rose threefold between 1950 and 1990, becoming the third leading cause of death following unintentional injuries and homicide.^12,^22,²³ Since that time, the suicide rate has declined in adolescents.²³ Men are more likely to complete suicide than are women, although women are more likely to attempt suicide than are men. Four times more men than women complete suicide,^8,²⁴ although women are three to four times more likely than men to attempt suicide.^24,²⁵ The reasons for these disparities have not been established clearly.

Whites and Native Americans attempt and commit suicide more than nonwhites.^5,^12,²⁴ African Americans and Hispanics have approximately half the suicide rate of whites.^24,^26,²⁷

Psychiatric Risk Factors

Psychiatric illness is the most powerful risk factor for both completed and attempted suicide. Psychiatric disorders are associated with more than 90% of completed suicides ^3,^4,^24,²⁸ and with the vast majority of attempted suicides.⁵^–⁷ Mood disorders, including major depressive disorder (MDD) and bipolar disorder, are responsible for approximately 50% of completed suicides, alcohol and drug abuse for 25%, psychosis for 10%, and personality disorders for 5%^29,³⁰ (Table 53-2).

Table 53-2 Percentage of Suicides with a Given Psychiatric Disorder

Condition	Percentage of Suicides
Affective illness	50
Drug or alcohol abuse	25
Schizophrenia	10
Character disorders	5
Secondary depression	5
Organic brain syndromes	2
None apparent	2

Up to 15% of patients with MDD or bipolar disorder complete suicide, almost always during depressive episodes ³¹; this represents a suicide risk 30 times greater than that of the general population.^32,³³ True lifetime risk may be somewhat lower, because these estimates (and those for the other diagnoses discussed later) typically derive from hospitalized patient samples.²⁹ The risk appears to be greater early in the course of a lifetime disorder, early on in a depressive episode,^11,³⁴ in the first week following psychiatric hospitalization,³⁵ in the first month following hospital discharge,³⁵ and in the early stages of recovery.³⁵ The risk may³⁶ or may not³⁷ be elevated by co-morbid psychosis. A 10-year follow-up study of almost 1,000 patients found that those who committed suicide within the first year of follow-up were more likely to be suffering from global insomnia, severe anhedonia, impaired concentration, psychomotor agitation, alcohol abuse, anxiety, and panic attacks, whereas those who committed suicide after the first year of follow-up were more likely to be suffering from suicidal ideation, severe hopelessness, and a history of suicide attempts.³⁶

Approximately 15% to 25% of patients with alcohol or drug dependence complete suicide,^34,³⁸ of which up to 84% suffer from both alcohol and drug dependence.³⁸ The suicide risk appears to be greatest approximately 9 years after the commencement of alcohol and drug addiction.^3,³⁹ The majority of patients with alcohol dependence who commit suicide suffer from co-morbid depressive disorders,^34,^40,⁴¹ and as many as one-third have experienced the recent loss of a close relationship through separation or death.⁴²

Nearly 20% of people who complete suicide are legally intoxicated at the time of their death.⁴³ Alcohol and drug abuse are associated with more pervasive suicidal ideation, more serious suicidal intent, more lethal suicide attempts, and a greater number of suicide attempts.⁴⁴ Use of alcohol and drugs may impair judgment and foster impulsivity.^35,⁴⁵

Approximately 10% of patients with schizophrenia complete suicide, mostly during periods of improvement after relapse or during periods of depression.^41,^46,⁴⁷ The risk for suicide appears to be greater among young men who are newly diagnosed,⁴⁷^–⁴⁹ who have a chronic course and numerous exacerbations, who are discharged from hospitals with significant psychopathology and functional impairment, and who have a realistic awareness and fear of further mental decline.^47,⁴⁹ The risk may also be increased with akathisia and with abrupt discontinuation of neuroleptics.³⁴ Patients who experience hallucinations (that instruct them to harm themselves) in association with schizophrenia, mania, or depression with psychotic features are probably at greater risk for self-harm and they should be protected.⁵⁰

Between 4% and 10% of patients with borderline personality disorder and 5% of patients with antisocial personality disorder commit suicide.⁵¹ The risk appears to be greater for those with co-morbid unipolar depression or alcohol abuse.^52,⁵³ Patients with personality disorders often make impulsive suicidal gestures or attempts; these attempts may become more lethal if they are not taken seriously. Even manipulative gestures can turn fatal.⁵⁰

As many as 15% to 20% of patients with anxiety disorders complete suicide,⁵⁴ and up to 20% of patients with panic disorder attempt suicide.⁵⁵ Although the risk of suicide in patients with anxiety and panic disorders may be elevated secondary to co-morbid conditions (e.g., MDD and alcohol or drug abuse), the suicide risk remains almost as high as that of major depression, even after co-existing conditions are taken into account.⁵⁶ The risk for suicide attempts may be elevated for women with an early onset and with co-morbid alcohol or drug abuse.⁵⁵

Medical Risk Factors

Medical illness, especially of a severe or chronic nature, is generally associated with an increased risk of suicide and is thus considered a risk factor for completed suicide even though there is a most likely a multifactorial relationship between medical illness and suicide.^16,^57,⁵⁸ Medical disorders are associated with as many as 35% to 40% of suicides⁵⁹ and with as many as 70% of suicides in those older than age 60.⁶⁰ Acquired immunodeficiency syndrome (AIDS), cancer, head trauma, epilepsy, multiple sclerosis, Huntington’s chorea, organic brain syndromes, spinal cord injuries, hypertension, cardiopulmonary disease, peptic ulcer disease, chronic renal failure, Cushing’s disease, rheumatoid arthritis, and porphyria have each been reported to increase the risk of suicide. Notably, however, few investigations concerning the increased risk for suicide in these populations have controlled for the effects of age, sex, race, psychiatric disorders, other medical disorders, or use of medications.

Patients with AIDS appear to have a suicide risk that is greater than that of the general population, and estimates of the increased risk range from 7 to 66 times greater than the general population.^29,^61,⁶² It is generally accepted that the risk of suicide in human immunodeficiency virus (HIV) infection is increased approximately sevenfold.^16,⁶¹ Testing for antibodies to HIV virus has resulted in an immediate and substantial decrease in suicidal ideation in those who turned out to be seronegative; no increase in suicidal ideation was detected in those who were seropositive.⁶³ Sexual orientation among men, in and of itself, has not been identified as an independent risk factor for completed suicide.^12,⁶⁴

Cancer patients have a suicide rate that is almost twice as great as that of the general population and seem to be at higher risk in the first 2 years after they are diagnosed.^61,⁶⁵ Head and neck malignancies are associated with an 11 times greater risk of suicide compared with the general population, possibly due to increased rates of tobacco and alcohol use in this population and the resultant facial disfigurement and loss of voice.⁶¹ In men, gastrointestinal cancers are associated with a greater risk of suicide, and in both sexes lung and upper airway malignancies are also associated with greater suicide risk.⁶¹ Other factors, including poor prognosis, poor pain control, fatigue, depression, hopelessness, delirium, disinhibition, prior suicide attempts, recent losses, and a paucity of social supports, may place cancer patients at greater risk.^66,⁶⁷

Like cancer patients, individuals with head trauma, multiple sclerosis, and peptic ulcer disease have approximately twice the risk of suicide of the general population.^61,^68,⁶⁹ In patients with head injuries, the risk appears to be greater in those who suffer severe injuries and in those who develop dementia, psychosis, character changes, or epilepsy.⁶⁸^–⁷⁰ In patients with multiple sclerosis, the risk may be higher for those diagnosed before age 40 and within the first 5 years after diagnosis.⁷¹ In patients with peptic ulcer disease, the increased risk is hypothesized to be due to co-morbid psychiatric and substance use (especially alcohol) disorders.^61,⁷⁰

Between the increased risk of suicide of approximately twofold for cancer, head trauma, multiple sclerosis, and peptic ulcer disease, and the increased risk in HIV-infected/AIDS patients estimated to be at least nearly sevenfold, there are a number of medical illnesses with intermediate increases in suicide risk. These illnesses include epilepsy, systemic lupus erythematosus, spinal cord injuries, Huntington’s disease, organic brain syndromes, and chronic renal disease. Patients with end-stage renal disease on hemodialysis may have the highest relative risk of all subgroups.^61,⁷² As many as 5% of patients with chronic renal failure who receive hemodialysis die from suicide; those who travel to medical centers for dialysis have a higher suicide rate than those who are dialyzed at home.¹⁰ The risk for suicide among these patients may be as high as 400 times that of the general population.⁷³

Patients with epilepsy are five times more likely than those in the general population to complete or to attempt suicide.^61,⁷⁴^–⁷⁶ Sufferers of temporal lobe epilepsy, with concomitant psychosis or personality changes, may be at greater risk.^61,^74,^75,⁷⁷

Delirious and confused patients may suffer from agitation and destructive impulses and be unable to protect themselves from harm.⁶⁶ In victims of spinal cord injury, the risk is actually greater for those with less severe injuries.^78,⁷⁹

Hypertensive patients ⁷⁰ and those with cardiopulmonary disease⁵⁰ may also have a higher risk for suicide than those in the general population. Although previous reports suggested that beta-blockers could contribute to increased risk by promoting depression,⁷⁰ recent studies suggest that beta-blockers do not increase the risk of developing depression.⁸⁰ Finally, an association between suicide and very low cholesterol levels has been reported, but the connection is still under investigation.^16,²⁹

Familial and Genetic Risk Factors

A family history of suicide, a family history of psychiatric illness, and a tumultuous early family environment have each been found to have an important impact on the risk for suicide.^12,⁵⁹ As many as 7% to 14% of persons who attempt suicide have a family history of suicide.⁸¹ A family history of suicide confers approximately a twofold increase in risk for suicide after family psychiatric history is controlled for.⁸² This increased suicide risk may be mediated through a shared genetic predisposition for suicide, psychiatric disorders, or impulsive behavior,^34,^48,⁸³ or through a shared family environment in which modeling and imitation are prominent.⁸⁴

Genetic factors are supported by evidence that monozygotic twins have a higher concordance rate for suicide and suicide attempts than dizygotic twins and by evidence that biological parents of adoptees who commit suicide have a higher rate of suicide than do biological parents of nonsuicidal adoptees.^29,^83,⁸⁵ However, little is known about the specific genetic factors that confer this risk.²⁹ Study has largely focused on serotonin neurotransmission, including genetic mutations in the rate-limiting enzyme in serotonin syn-thesis, L-tryptophan hydroxylase, serotonin receptors, and the serotonin transporter, but this investigation is still preliminary.^82,⁸⁶^–⁸⁸ Overall, it is estimated that one-third to one-half the risk of suicide is genetically mediated.⁸²

Numerous familial environmental factors may also contribute to suicide risk. A tumultuous early family environment (including factors of early parental death, parental separation, frequent moves, and emotional, physical, or sexual abuse) increases the risk for suicide.⁸⁹ Children’s risk of future suicidal behavior may also be increased by suicidal behavior in important family members through modeling.²⁹

Social Risk Factors

Widowed, divorced, or separated adults are at greater risk for suicide than are single adults, who are at greater risk than married adults.^90,⁹¹ Married adults with young children appear to carry the lowest risk.^35,^50,⁵⁹ Living alone substantially increases the risk for suicide, especially among adults who are widowed, divorced, or separated.³⁵ Social isolation from family, relatives, friends, neighbors, and co-workers also increases the chance of suicide.^48,⁵⁹ Conversely, the presence of social supports is protective against suicide.⁸²

Significant personal losses (including diminution of self-esteem or status ^59,⁶⁰) and conflicts also place individuals, particularly young adults and adolescents, at greater risk for suicide.^3,⁹² Bereavement following the death of a loved one increases the risk for suicide over the next 4 or 5 years, particularly for people with a psychiatric history (including suicide attempts) and for people who receive little family support.³⁴ Unemployment, which may produce or exacerbate psychiatric illness or may result from psychiatric illness,³⁴ increases the likelihood of suicide and accounts for as many as one-third to one-half of completed suicides.^43,⁵⁹ This risk may be particularly elevated among men.³⁴ Financial and legal difficulties also increase the risk for suicide.^12,^35,⁹³

The presence of one or more firearms in the home appears to increase the risk of suicide independently for both genders and all age-groups, even when other risk factors, such as depression and alcohol abuse, are taken into account.^6,^92,⁹⁴ For example, adolescents with a gun in the household have suicide rates between 4 and 10 times higher than other adolescents.^23,⁹⁵

Past and Present Suicidality

A history of suicide attempts is one of the most powerful risk factors for completed and attempted suicide.^12,⁹⁶ As many as 10% to 20% of people with prior suicide attempts complete suicide.^10,^17,⁹⁷ The risk for completed suicide following an attempted suicide is almost 100 times that of the general population in the year following the attempt; it then declines but remains elevated throughout the next 8 years.³⁴ People with prior suicide attempts are also at greater risk for subsequent attempts and have been found to account for approximately 50% of serious overdoses.⁹⁸ The clinical use of past suicide attempts as a predictive risk factor may be limited in the elderly because the elderly make fewer attempts for each completed suicide.¹⁹^–²¹ ⁵⁹

The lethality of past suicide attempts slightly increases the risk for completed suicide,³⁴ especially among women with psychiatric illness.⁴⁰ The dangerousness of an attempt, however, may be more predictive of the risk for suicide in those individuals with significant intent to suicide and a realization of the potential lethality of their actions.⁹⁹

The communication of present suicidal ideation and intent must be carefully evaluated as a risk factor for completed and attempted suicide. As many as 80% of people who complete suicide communicate their intent either directly or indirectly.⁵⁹ Death or suicide may be discussed, new wills or life insurance policies may be written, valued possessions may be given away, or uncharacteristic and destructive behaviors may arise.⁵⁹

People who intend to commit suicide may, however, be less likely to communicate their intent to their health care providers than they are to close family and friends.⁴⁶ Although 50% of people who commit suicide have consulted a physician in the month before their death, only 60% of them communicated some degree of suicidal ideation or intent to their physician.^3,⁴⁶ In a study of 571 cases of completed suicide who had met with their health care professional within 4 weeks of their suicide,¹⁰⁰ only 22% discussed their suicidal intent. Many investigators believe that ideation and intent may be more readily discussed with psychiatrists than with other physicians.^100,¹⁰¹

Hopelessness, or negative expectations about the future, is a stronger predictor of suicide risk than is depression or suicidal ideation,^102,¹⁰³ and may be both a short-term and long-term predictor of completed suicide in patients with major depression.⁴⁶

Contact with Physicians

Nearly half of the people who commit suicide have contact with their primary care provider (PCP) within 1 month of committing suicide.^35,^46,¹⁰⁴ Approximately three-quarters of people who commit suicide saw a PCP in the year before the suicide.¹⁰⁴ Many of these individuals seek treatment from their PCP for somatic rather than psychiatric complaints.¹⁰⁵ Rates of psychiatric encounters in the period before completed suicides are lower than those for primary care contacts.¹⁰⁴ In the month before a completed suicide, approximately one-fifth of suicide completers obtained mental health services, and in the year before a completed suicide, approximately one in three suicide completers had contact with a mental health professional.¹⁰⁴

PATHOPHYSIOLOGY

Suicide is a behavioral outcome with a large number of contributing factors, rather than a disease entity in itself. Therefore, in order to understand the pathophysiology of suicidality, it is necessary to examine the differences between individuals with a given set of predisposing factors who do not attempt or complete suicide and those who do. Research has focused on a wide array of neurobiological and psychological topics in an attempt to better understand the pathophysiology of suicide. Neurobiological inquiries have included neurotransmitter analyses, genetic studies, neuroendocrine studies, biological markers, and imaging studies.¹⁶ Psychological aspects of suicide typically focus on psychodynamic and cognitive perspectives.

Neurobiology

Of all the neurotransmitters, the relationship of serotonin to suicidality has been most widely studied.¹⁶ An association between decreased cerebrospinal fluid (CSF) levels of the serotonin metabolite 5-hydroxy indole acetic acid (HIAA) and serious suicide attempts was first described in the 1970s.¹⁰⁶ Since then, evidence of an association between the serotonergic system and suicidality has continued to grow, with most subsequent studies finding decreased CSF 5-HIAA levels in individuals who attempt suicide.^107,¹⁰⁸ There have also been reports of a blunted prolactin response to fenfluramine challenge, a marker for serotonergic dysfunction.^82,¹⁰⁷^–¹⁰⁹ This finding is independent of underlying psychiatric diagnosis, that is, it is consistent for suicide attempters with major depression, schizophrenia, and personality disorders compared to diagnosis-matched controls without a history of attempting suicide.^107,¹⁰⁸ Low levels of 5-HIAA are associated with more serious attempts, and are negatively correlated with the degree of injury in the most recent suicide attempt or most serious past attempt.^107,^108,¹¹⁰ That is, higher-lethality past attempts are associated with lower CSF 5-HIAA levels. Finally, low CSF 5-HIAA has also been shown to predict future attempted and completed suicide.¹¹¹

Similarly, postmortem brainstem analysis has shown a reduction in serotonin and its metabolite 5-HIAA in suicide completers.^29,^107,^112,¹¹³ This reduction in serotonin and 5-HIAA was similar for depressed, schizophrenic, personality-disordered, and alcoholic patients, showing that decreased brainstem serotonin activity correlates with completed suicide irrespective of diagnosis.^107,¹¹³ Other brainstem abnormalities associated with suicide victims are the presence of an increased number of serotonin neurons compared to controls.^16,^29,¹¹⁴

Serotonin receptors, in particular the serotonin transporter (SERT), have also been implicated in the neurophysiology of suicide. There is evidence for both presynaptic and postsynaptic changes in the prefrontal cortex of suicide completers, although not all studies have demonstrated these findings.^29,¹⁰⁷ Specific findings in the prefrontal cortex of suicide victims include a decrease in presynaptic serotonin transporter binding on nerve terminals and increases in postsynaptic serotonin_1A and serotonin_2A receptors.^16,^29,^107,¹¹⁴ Changes in receptor expression and binding are also accompanied by changes in intracellular signaling.^108,^115,¹¹⁶ Abnormalities include low protein kinase C activity in the prefrontal cortex, low cyclic adenosine monophosphate (cAMP)–mediated activity in the hippocampus and prefrontal cortex, and a decreased number of G-protein alpha subunits.^108,¹¹⁵^–¹¹⁷

Changes in norepinephrine transmission in suicide have also been investigated, but to a lesser degree than have serotonergic changes. As a result, the implications of studies on the noradrenergic system remain comparatively preliminary. Postmortem brainstem analysis of the locus coeruleus of suicide victims with major depression has revealed a decreased number of noradrenergic neurons.^107,^108,^117,¹¹⁸ However, this finding may be the result of illness, a stress-related phenomenon, or other factors.^107,^108,^117,¹¹⁸ Specifically, because of stress-related changes in the noradrenergic system during stress, the stress preceding suicide may be the cause of other observed changes in the brainstems of suicide victims, which include alterations in adrenergic receptor populations and tyrosine hydroxylase activity, the rate-limiting step in norepinephrine synthesis.^29,^82,¹¹⁷ Overall, CSF studies have shown no significant difference in norepinephrine metabolites in suicidal behavior.^82,¹¹⁹

Although some investigation into the role of dopamine in suicidal behavior and suicide has been done, overall, the data are relatively inconclusive. Postmortem studies are too few to determine whether there are changes in levels of dopamine and its metabolites in the brains of suicide victims.¹¹⁷ CSF levels of dopamine metabolites have, in general, not been shown to differ in individuals with suicidal behavior compared to others.^82,^119,¹²⁰ Low levels of the dopamine metabolite homovanillic acid (HVA) have been shown in individuals with major depression who attempted suicide.¹¹⁷ However, it is unclear whether a relationship between dopamine and suicide exists independent of the known association of major depression and dopamine down-regulation.¹¹⁷

The hypothalamic-pituitary-adrenal (HPA) axis has been implicated in the pathophysiology of suicide, although not all studies of the relationship between the HPA axis abnormalities and suicidal behavior have reached the same conclusions.^16,^29,^82,¹¹⁷ In general, heightened HPA axis activity, as evidenced by abnormal dexamethasone suppression test (DST) results, has been shown in major depression and thought to be associated with suicidality.^16,^29,^82,^108,¹¹⁷ However, while some studies of the relationship between HPA axis activity and suicidality have shown a relationship between dexamethasone nonsuppression and suicidality, other recent investigations have not found a correlation.⁸² Urinary cortisol production has been shown to be elevated in suicidal behavior, and this finding has been replicated in CSF studies and postmortem brain analysis.¹⁶ Elevated urinary cortisol and dexamethasone nonsuppression have also been shown to correlate with future suicidality.^29,^82,^108,¹¹⁷

Psychological, Psychodynamic, and Neuropsychological Perspectives

The psychodynamic and psychological understanding of suicide encompasses a vast literature; nonetheless, according to one expert, “The psychological operation of this extraordinary phenomenon, whatever its neurochemical matrix may be, is far from obvious.”¹²¹ In conceptualizing the notion of murder turned against the self, Freud described confusion between the self and another person who is both loved and hated as central to suicide.^121,¹²² Suicide can, then, be conceptualized as anger turned on one’s self or anger toward others directed at the self.¹²¹^–¹²³ Suicide has also been seen as motivated by three driving forces: the wish to die, the wish to kill, and the wish to be killed.¹²³ Deficits in ego functioning have also been postulated to predispose to suicide,¹²¹ as have poor object relations.¹²³ Maltsberger has identified a core set of principles that are generally true in suicide; these include a central connection to object loss, mental anguish, confusion of parts of the self with others, the presence of fantasies of resurgence into a new life, and difficulty in self-regulation.¹²¹

Hopelessness is a central psychological correlate of suicide. Extensive study on hopelessness has shown a stronger correlation among hopelessness and suicidal ideation and suicide than hopelessness and depression and depression and suicide.⁸² Hopelessness may be the best overall predictor of suicide.⁸² Shame, worthlessness, and poor self-esteem are also key concepts in the understanding of suicide; individuals with early traumatic relationships may be particularly vulnerable to narcissistic wounds.¹²³ Shneidman,¹²⁴ in setting forth his psychological approach to suicide, has argued that the psychology of suicide involves intense psychological pain, which he has termed psychache. This psychache occurs due to unmet psychological needs (specifically the vital needs individuals require when under duress).¹²⁴ He has identified five clusters of psychological pain that predispose to suicide; these center on thwarted love, acceptance and belonging, fractured control, assaulted self-image and avoidance of shame, ruptured key relationships, and excessive rage, anger, and hostility.¹²⁴ Poor coping skills, antisocial traits, hostility, hopelessness, dependency, and self-consciousness have also been associated with suicide.¹²³

One recent report found that depressed patients with either thoughts of death or suicidal ideation had lower self-confidence, overdependency on others, and high intro-punitiveness compared with depressed patients without thoughts of death or suicide.¹²⁵ Other research has postulated correlations between observed neuroanatomic, neurotransmitter, and neuroendocrine findings in suicide and attendant cognitive traits of loser status, no escape, and no rescue as central to understanding suicidal behavior.¹⁰⁸

CLINICAL FEATURES AND DIAGNOSIS

The patient at risk for suicide varies along a continuum (from an individual with private thoughts of wanting to be dead or to commit suicide, to a gravely ill individual who requires emergent medical attention as the result of a self-inflicted injury aimed to end his or her life). Therefore, there is no characteristic presentation of the suicidal patient. As a result, the evaluation of suicide risk depends on clinical assessment of suicide risk in all patients and, in particular, on a detailed clinical examination of the patient who has contemplated, threatened, or attempted suicide. The thoughts and feelings of the individual must be elicited and placed in the context of known risk factors for suicide.

Although useful as a guide to patient populations who may be more likely to commit or to attempt suicide, risk factors alone are neither sensitive nor specific in the prediction of suicide. Their pervasive prevalence in comparison with the relatively low incidence of suicide in the general population may also lead to high false-positive rates. A multiple logistic regression model that used risk factors (such as age, sex, psychiatric diagnoses, medical diagnoses, marital status, family psychiatric history, prior suicide attempts, and suicidal ideation) failed to identify any of the 46 patients who committed suicide over a 14-year period from a group of 1,906 people with affective disorders.¹²⁶ Similarly, a multiple regression analysis aimed at predicting risk classification by treatment disposition of individuals after suicide attempts had only slightly more than a two-thirds concordance with the decisions made by the treating clinician.¹²⁷

An evaluation for suicide risk is indicated for all patients who have made a suicide attempt, who have voiced suicidal ideation or intent, who have admitted suicidal ideation or intent on questioning, or whose actions have suggested suicidal intent despite their protests to the contrary. All suicide attempts and thoughts of suicide should be taken seriously, regardless of whether the actions or thoughts appear manipulative in nature. The work group on suicidal behaviors of the American Psychiatric Association has outlined the four critical features of a comprehensive assessment of patients with suicidal behaviors in its 2003 practice guideline: a thorough psychiatric evaluation, specific inquiry about suicidality, establishment of a multiaxial diagnosis, and estimation of suicide risk.¹²³ The key facets of each of these components are detailed in Table 53-3.

Table 53-3 Components of the Suicide Evaluation

Conduct a thorough psychiatric examination

• Establish initial rapport

• Combine open-ended and direct questions

• Gather data from family, friends, and co-workers

• Conduct a mental status examination

Suicide assessment

• Ask specifically about thoughts of suicide and plans to commit suicide

• Examine the details of the suicide plan

• Determine the risk/rescue ratio

• Assess the level of planning and preparation

• Evaluate the degree of hopelessness

• Identify precipitants

Establish a multiaxial diagnosis

• Obtain history

• Use data from a psychiatric examination

• Incorporate data from prior or current treaters

Estimate suicide risk

• Evaluate risk factors

• Evaluate available social supports

The approach to the patient at potential risk for suicide should be nonjudgmental, supportive, and empathic. The initial establishment of rapport may include an introduction, an effort to create some degree of privacy in the interview setting, and an attempt to maximize the physical comfort of the patient for the interview.⁵⁰ The patient who senses interest, concern, and compassion is more likely to trust the examiner and to provide a detailed and accurate history. Often ambivalent about their thoughts and plans, suicidal patients may derive significant relief and benefit from a thoughtful and caring evaluation.^48,⁵⁰

The patient should be questioned about suicidal ideation and intent in an open and direct manner. Patients with suicidal thoughts and plans are often relieved and not offended when they find someone with whom they can speak about the unspeakable. Patients without suicidal ideation do not have the thoughts planted in their mind and do not develop a greater risk for suicide.^48,^50,¹²⁸ General questions concerning suicidal thoughts can be introduced in a gradual manner while obtaining the history of present illness. Questions such as “Has it ever seemed like things just aren’t worth it?”⁵⁰ or “Have you had thoughts that life is not worth living?”⁴⁸ may lead to a further discussion of depression and hopelessness. “Have you gotten so depressed that you’ve considered killing yourself?”⁵⁰ or “Have you had thoughts of killing yourself?”⁴⁷ may open the door to a further evaluation of suicidal thoughts and plans.

Specific questions concerning potential suicide plans and preparations must follow any admission of suicidal ideation or intent. The patient should be asked when, where, and how an attempt would be made, and any potential means should be evaluated for feasibility and lethality. An organized and detailed plan involving an accessible and lethal method may place the patient at higher risk for suicide.⁴³ The seriousness of the wish or the intent to die must also be assessed. The patient who has begun to carry out the initial steps of a suicide plan, who wishes to be dead, and who has no hopes or plans for the future may be at greater risk. The last-mentioned domain (plans for the future) may be assessed by asking questions such as “What do you see yourself doing five years from now?” or “What things are you still looking forward to doing or seeing?”⁵⁰

Many clinicians have addressed the issues of lethality and intent by means of the risk/rescue ratio.^123,¹²⁹ The greater the relative risk or lethality and the lesser the likelihood of rescue of a planned attempt, the more serious is the potential for a completed suicide. Although often useful, the risk/rescue ratio cannot be merely applied as a simple formula; instead, one must examine and interpret the particular beliefs of a given patient. For example, a patient may plan an attempt with a low risk of potential harm but may sincerely wish to die and believe that the plan will be fatal; the patient may thus have a higher risk for suicide. Conversely a patient may plan an attempt that carries a high probability of death, such as an acetaminophen overdose, but may have little desire to die and little understanding of the severity of the attempt; the patient may thus have a lower risk.^43,¹²³

The clinician must attempt to identify any possible precipitants for the present crisis in an effort to understand why the patient is suicidal. The patient who must face the same problems and stressors following the evaluation or who cannot or will not discuss potential precipitants may be at greater risk for suicide.⁴³ The clinician must also assess the social support in place for a given patient. A lack of outpatient care providers, family, or friends may elevate potential risk.^48,⁵⁹

The examiner who interviews a patient after a suicide attempt needs to evaluate the details, seriousness, risk/rescue ratio, and precipitants of the attempt. The patient who carries out a detailed plan, who perceives the attempt as lethal, who thinks that death will be certain, who is disappointed to be alive, and who must face unchanged stressors will be at a continued high risk for suicide. The patient who makes a calculated, premeditated attempt may also be at a higher risk for a repeat attempt than the patient who makes a hasty, impulsive attempt (out of anger, a desire for revenge, or a desire for attention), or the patient who is intoxicated.⁵⁰

A thorough psychiatric, medical, social, and family history of the patient who may be at risk for suicide should be completed to evaluate the presence and significance of potential risk factors. Particular attention should be paid to the presence of MDD, alcohol or drug abuse, psychotic disorders, personality disorders, and anxiety disorders. The presence of multiple significant risk factors may confer an additive risk.

A careful mental status examination allows the clinician to detect psychiatric difficulties and to assess cognitive capacities. Important aspects to evaluate in the examination include level of consciousness, appearance, behavior, attention, mood, affect, language, orientation, memory, thought form, thought content, perception, insight, and judgment.^129,¹³⁰ A psychiatric review of systems aids in the detection of psychiatric disease.

The clinician should interview the family and friends of the patient at risk to corroborate gathered information and to obtain new and pertinent data. The family may provide information that a patient is hesitant to provide and that may be essential to his or her care.^43,^48,⁵⁰ A patient who refuses to discuss an attempt or insists that the entire event was a mistake may speak in an open and honest manner only when confronted with reports from his or her family. The evaluation of suicidal risk and the protection of the patient at risk are emergent procedures, which may take precedence over the desire of the patient for privacy and the maintenance of confidentiality in the physician-patient relationship. Concern over a life-or-death situation may obviate obtaining formal consent from the patient before speaking to family and friends.⁵⁰

TREATMENT OF SUICIDE RISK

The treatment of suicide risk begins with stabilization of medical sequelae of suicidal behaviors. Attention to current or potential medical conditions must be prompt, and medical evaluations must be complete. The severity of the psychiatric presentation should not distract a clinician from his or her obligation to provide good medical care.⁴³ Once the patient is medically stable, or if the patient is suicidal but has not acted on suicidal impulses, the focus of treatment can shift to initiation of treatment for the underlying causes of the desire for death. Components of the treatment of suicide risk include providing a safe environment for the patient, determining an appropriate treatment setting, developing a treatment plan involving appropriate somatic and psychotherapeutic interventions, and reassessing safety, suicide risk, psychiatric status, and treatment response in an ongoing fashion¹²³ (Table 53-4).

Table 53-4 Treatment of Suicide Risk

Stabilize the medical situation

Create a safe environment

• Remove potential means for self-harm

• Provide frequent supervision

• Use restraints as needed

• Detain involuntarily if necessary

Identify and treat underlying mental illness Identify and modify other contributing factors

Throughout the evaluation and treatment of the suicidal patient, safety must be ensured until the patient is no longer at imminent risk for suicide. Appropriate intervention and the passage of time may aid in the resolution of suicidal ideation and intent.^43,⁵⁰ A patient who is at potential risk for suicide and who threatens to leave before an adequate evaluation is completed must be detained, in accordance with statutes in most states that permit the detention of individuals deemed dangerous to themselves or others.¹³¹ Patients who attempt to leave nonetheless should be contained by locked environments or restraints.⁴³

Potential means for self-harm should be removed from the reach of a patient at risk. Sharp objects (such as scissors, sutures, needles, glass bottles, and eating utensils) should be removed from the immediate area. Open windows, stairwells, and structures to which a noose could be attached must be blocked. Medications or other dangerous substances that patients may have in their possession must be secured by staff in a location out of the patient’s access.⁴³ Appropriate supervision and restraint must be provided at all times for a patient at risk for suicide. Frequent supervision, constant one-to-one supervision, physical restraints, and medications may be used alone or in combination in an effort to protect a patient at risk. The least restrictive means that ensures the safety of the patient should be used.

A decision about the appropriate level of care and treatment setting for the suicidal patient is critical. The patient’s safety is paramount, and decisions about level of care—from discharge home with outpatient follow-up to involuntary hospitalization—should be based on risk determinations and methods most likely to protect the patient from self-harm, even when the patient disagrees. Those who are at high risk for suicide, or who cannot control their suicidal urges, should be admitted to a locked psychiatric facility. A patient who is at high risk but who refuses hospitalization should be committed involuntarily.

A patient who requires hospitalization should be informed of the disposition decision in a clear, direct manner. Possible transfers should proceed as quickly and efficiently as possible because a patient may become quite tense and ambivalent about the decision to hospitalize. Those who agree to voluntary hospitalization and who cooperate with caregivers may have the highest likelihood of successful treatment.⁵⁰ A 3-year study of patients at a university emergency room in Zurich found that older patients were more likely to be hospitalized after a suicide attempt and that nearly half of patients admitted for psychiatric treatment were voluntary.¹²⁷ In a regression analysis of the same sample, more aggressive methods of suicide attempt (defined as not overdose or cutting), a history of previous inpatient treatment, and a current diagnosis of psychosis or schizophrenia were associated with inpatient admission.¹²⁷

The clinician should always take a conservative approach to the treatment of suicidal risk and the maintenance of patient safety and err, if necessary, on the side of excess restraint or hospitalization. From a forensic standpoint, the clinician sued for battery secondary to the use of restraints or to involuntary commitment would be easier to defend than the clinician sued for negligence secondary to a completed suicide. Acting in accordance with good clinical judgment in the best interest of the patient brings little danger of liability.⁵⁰ Adequate documentation should include the thought processes behind decisions to supervise, restrain, discharge, or hospitalize.⁵⁰

Although managed care may place pressure on a clinician to avoid hospitalization through the use of less costly alternatives, there is no substitute for sound clinical judgment.¹²³ In particular, safety contracts or suicide prevention contracts, while intended to manage risk, are generally overvalued and of limited utility.^123,¹³² Specifically, suicide contracts depend on the subjective beliefs of the psychiatrist and the patient and not on objective data; they have never been shown to be clinically efficacious.^123,¹³² In addition, many suicide attempters and completers had suicide contracts in place at the time of the suicidal act.^123,^133,¹³⁴ Finally, a suicide contract is not a legal contract and it has limited utility, if any, if litigation should ensue from a completed suicide.^123,^135,¹³⁶

Somatic therapies to target underlying psychiatric illness are a mainstay of the management of the suicidal patient. However, while psychiatric illness is a significant risk factor for suicide and treatment of underlying psychopathology is associated with decreased suicide risk, with few exceptions psychiatric medications have not independently been associated with a decrease in suicide. The two notable exceptions are long-term treatment with lithium (in affective illness)^137,¹³⁸ and clozapine (in schizophrenia).^139,¹⁴⁰

Because depression is the psychiatric diagnosis most associated with suicide, psychopharmacological treatment of depression is a central facet of management of suicide risk. However, antidepressants have not been shown to decrease suicide risk.^123,¹⁴¹ Although one recent study found a higher rate of suicide after discontinuation of antidepressants compared with during antidepressant treatment, the study was small and further investigation is required.¹⁴²

Controversy regarding the relationship of selective serotonin reuptake inhibitor (SSRI) antidepressant medications and suicide has now spanned more than a decade. In the early 1990s, reports of a possible increase in suicidal ideation and suicidal behavior in both adults and children on SSRIs emerged.^143,¹⁴⁴ In 2004, the Food and Drug Administration (FDA) issued a “black box warning” for all antidepressant drugs related to the risk of suicide in pediatric patients.¹⁴⁵ Nonetheless, controversy about SSRIs and suicide persists, in both adults and children. For example, in 2004, before the FDA advisory opinion, the American College of Neuropsychopharmacology’s Task Force on SSRIs and Suicidal Behavior in Youth failed to find an association between SSRIs and increased suicidality in children.¹⁴⁶ Another study also showed an improvement in depression and a reduction in suicidal thinking with fluoxetine and with fluoxetine combined with cognitive-behavioral therapy (CBT), when compared with placebo and CBT alone.¹⁴⁷

In adults, there has been similar controversy about a possible relationship between SSRIs and increased suicidality and self-harm. Multiple large studies that assessed the risk of suicide and self-harm have been completed; they largely concluded that SSRIs were not associated with a greater risk of suicide or violence.^123,¹⁴⁸^–¹⁵¹ However, debate has continued.¹⁵² Most recently (2005), three papers published in the British Medical Journal reached varying conclusions and raised some questions about the data used in a previous analysis. One analysis of 477 randomized control trials of more than 40,000 patients found no evidence that SSRIs increased the risk of suicide, but found weak evidence of an increased risk of self harm.¹⁵³ A second review of randomized controlled trials with a total of 87,650 patients reached the opposite conclusion, finding an association between suicide attempts and the use of SSRIs.¹⁵⁴ A case-control study of 146,095 individuals with a first prescription for depression found no greater risk of suicide or nonfatal self-harm in adults prescribed SSRIs as opposed to those prescribed tricyclic antidepressants (TCAs), although there was some weak evidence for increased nonfatal self-harm with use of SSRIs in patients under age 18 years.¹⁵⁵ What is clear from review of the data on SSRIs is that more study is needed. Because SSRIs are prescribed for treatment of an underlying illness characterized by anxiety, agitation, and suicidality, it is difficult to separate out drug effect from illness effect.¹²³ Notwithstanding the continuing controversy, SSRIs do have the obvious advantage over TCAs and monoamine oxidase inhibitor (MAOI) antidepressants of being relatively safe in overdose.

Finally, because pharmacotherapy for depression typically requires several weeks for onset of efficacy, electroconvulsive therapy (ECT) may be indicated in cases in which suicide risk remains high or antidepressants are contraindicated.^123,¹⁵⁶ ECT is associated with a decrease in short-term suicidal ideation.¹²³ Its use is best established for depression, and it may also be recommended for pregnant patients and for patients who have not responded to pharmacological interventions.¹²³

Psychotherapeutic interventions are widely used to manage suicide risk, although few studies have addressed psychotherapy outcomes in the reduction of suicidality. None-theless, clinical practice and consensus supports the use of psychotherapy and other psychosocial interventions, notwithstanding the need for further study.¹²³ There is emerging evidence of the efficacy of multiple psychotherapeutic modalities in the treatment of depression, borderline personality disorder, and suicide risk per se, including psychodynamic psychotherapy, CBT, dialectical behavioral therapy, and interpersonal psychotherapy.¹²³

DIFFICULTIES IN THE ASSESSMENT OF SUICIDE RISK

Clinicians may encounter obstacles with certain patients, or within themselves, during the evaluation of suicide risk. They must be adept in the examination of patients who are intoxicated, who threaten, or who are uncooperative, and they must be aware of personal feelings and attitudes (e.g., anxiety, anger, denial, intellectualization, or over-identification) to allow for better assessment and management of the patient at risk (Table 53-5).

Table 53-5 Common Reactions of Clinicians to Suicide

Anger
Anxiety
Depression
Denial
Helplessness
Indifference
Intellectualization
Over-identification
Rejection

A patient who is intoxicated may voice suicidal ideation or intent that is (frequently) retracted when sober. A brief initial evaluation while the patient is intoxicated and his or her psychological defenses are impaired may reveal the depth of suicidal ideation or the reasons behind a suicide attempt.⁵⁰ A more thorough final examination when he or she is sober must also be completed and documented.^43,⁵⁰

A patient who threatens should be evaluated in the presence of security officers and should be placed in restraints as necessary to protect both the individual and the staff.⁵⁰ Those who are uncooperative may refuse to answer questions despite all attempts to establish rapport and to create a supportive and empathic connection. Stating “I’d like to figure out how to be of help, but I can’t do that without some information from you” in a calm but firm manner might be helpful. Patients should be informed that safety precautions will not be discontinued until the evaluation can be completed and that they will not be able to sign out against medical advice. Their capacity to refuse medical treatments should be carefully questioned.⁵⁰ A patient who refuses to cooperate until restraints are removed should be reminded of the importance of the evaluation and should be enlisted to cooperate with the goal of removing the restraints in mind. Statements such as “We both agree that the restraints should come off if you don’t need them. I am very concerned about your safety, and I need you to answer some questions before I can decide if it’s safe to remove the restraints” might be helpful.⁵⁰

A clinician may experience personal feelings and attitudes toward a patient at risk for suicide, which must be recognized and which must not be allowed to interfere with appropriate patient care.¹²¹ Clinicians may feel anxious because of the awareness that an error in judgment might have fatal consequences. They may feel angry at a patient with a history of multiple gestures or at a patient who has used trivial methods, often resulting in poor evaluations and punitive interventions. Angry examiners may inappropriately transfer a patient with a low risk for suicide to a psychiatric facility or may discharge a patient with a high risk to home.⁵⁰

Some clinicians are prone to experience denial as they evaluate and treat patients at risk for suicide. They may conspire with the patient or family in the stance that voiced suicidal ideation was “just talk” or that an attempt was “just an accident.” Others may practice intellectualization and choose to believe that suicide is “an act of free will” and that patients should have the personal and legal right to kill themselves.⁴³

Clinicians commonly over-identify with patients with whom they share personal characteristics. The thought “I would never commit suicide” may become translated into the thought “This patient would never commit suicide,” and serious risk may be missed.⁵⁰ The examiner may try to assure patients that they will be fine or may try to convince them that they do not feel suicidal. Patients may thus be unable to express themselves fully and may not receive proper evaluation and treatment.

A clinician who performs evaluations for patients who have made suicide attempts and who have been admitted to general hospital floors has to be aware of his or her own reactions to the patient, as well as to those of the staff. In addition, medical and surgical staff often develop strong feelings toward patients who have attempted suicide and at times they wish that these patients were dead. The clinician must diffuse such charged situations, perhaps by holding group meetings for those involved to make them more aware of their negative feelings so that they are not acted out.¹⁵⁷ Such intervention may prevent mismanagement and premature discharge.

REFERENCES

1 Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: final data for 2002. Natl Vital Stat Rep. 2004;53(5):1-116.

2 McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2002 emergency department summary. Adv Data. 2004;340:1-35.

3 Rich CL, Young D, Fowler RC. San Diego suicide study: young vs. old subjects. Arch Gen Psychiatry. 1986;43:577-582.

4 Brent DA. Correlates of medical lethality of suicide attempts in children and adolescents. J Am Acad Child Adolesc Psychiatry. 1987;26:87-89.

5 Moscicki EK, O’Carroll P, Regier D, et al. Suicide attempts in the epidemiologic catchment area study. Yale J Biol Med. 1988;61:259-268.

6 Brent DA, Perper JA, Goldstein CE, et al. Risk factors for adolescent suicide. Arch Gen Psychiatry. 1988;45:581-588.

7 Andrews JA, Lewinsohn PM. Suicidal attempts among older adolescents: prevalence and co-occurrence with psychiatric disorders. J Am Acad Child Adolesc Psychiatry. 1992;31:655-662.

8 Moscicki E. Epidemiology of suicide. In: Goldsmith S, editor. Risk factors for suicide. Washington, DC: National Academy Press, 2001.