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Suicidal Behavior

By Paula J. Clayton, MD, Professor Emeritus;, University of Minnesota School of Medicine; American Foundation for Suicide Prevention

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Suicidal behavior includes completed suicide and attempted suicide. Thinking about, considering, or planning suicide are referred to as suicide ideation.

  • Completed suicide: A suicidal act that results in death.

  • Attempted suicide: A nonfatal, self-directed, potentially injurious act intended to result in death but may or may not result in injury

  • Nonsuicidal self-injury (NSSI): A self-inflicted act that causes pain or superficial damage but is not intended to cause death

Epidemiology

Statistics on suicidal behavior are based mainly on death certificates and inquest reports and underestimate the true incidence. To provide more reliable information, the CDC established the National Violent Death Reporting System (NVDRS); it is a state-based system that collects facts about each violent incident from various sources to provide a clearer understanding of the causes of violent deaths (homicides and suicides). The NVDRS is currently in place in 40 states.

In the US, suicide is the 10th leading cause of death, with a death rate of 13.8/100,000 and almost 41,000 completed suicides in 2015. In the US, 121 people die by suicide each day. As a cause of death, it ranks as follows:

  • 2nd among people aged 15 to 34

  • 3rd among those aged 10 to 14

  • 4th among those aged 35 to 44+

The age group with the highest suicide rate is now people aged 45 to 64 yr, resulting from a recent significant increase. Why this rate has increased is unknown; however, the following may have contributed:

  • Years ago, as teenagers, this group had a higher rate of depression than older groups, and researchers predicted the suicide rate would rise as they aged..

  • This rate includes the increased number of suicides in the military and veterans (20% of suicides are in that group).

  • This rate may reflect increased abuse of prescription and nonprescription drugs and a response to the poor economy.

The second highest rate of suicide is in people ≥ 85 yr.

In the 1990s , youth suicide rates decreased after more than a decade of steady increase, only to again start climbing steadily.

In all age groups, male deaths by suicide outnumber female deaths 3.5 to 1. The reasons are unclear, but possible explanations include

  • Men are less likely to seek help when they are distressed.

  • Men have a higher prevalence of alcohol and drug abuse, which leads to suicidal tendencies.

  • Men are more aggressive and use more lethal means when attempting suicide.

  • The number of suicides in men includes suicides in the military and veterans who have a higher proportion of men to women.

In 2015, white men accounted for 7 in every 10 suicides.

In 2015, > 1.1 million people reported making a attempt suicide. About 25 attempts are made for every death that occurs by suicide. Many make repeated attempts. Only 5 to 10% of people who make an attempt eventually die by suicide; however in the elderly, 1 in every 4 suicide attempts ends in death. Women attempt suicide 2 to 3 times more often than men; among girls aged 15 to19 yr, there may be 100 attempts to every 1 attempt among boys of the same age.

A suicide note is left by about 1 in 6 people who complete suicide. The content may indicate the reasons for the suicide (including a mental disorder).

Copycat suicide or suicide contagion accounts for about 10% of the suicides. Group suicides are extremely rare, as are murder/suicides. Rarely, people commit an act (eg, brandish a weapon) that forces law enforcement agents to kill them—called suicide by police.

Etiology

Suicidal behaviors usually result from the interaction of several factors.

The primary remediable risk factor in suicide is

The amount of time spent in an episode of depression is the strongest predictor of suicide. Also, suicide appears to be more common when severe anxiety is part of major depression or bipolar depression. Risk of suicidal thoughts and attempts may increase in younger age groups after antidepressant drugs are started (see Suicidal Behavior : Treatment of depression and risk of suicide and Depressive Disorders in Children and Adolescents : Suicide risk and antidepressants).

Other risk factors for suicide include the following:

  • Most other serious mental disorders

  • Use of alcohol, drugs of abuse, and prescription analgesics

  • Previous suicide attempts

  • Serious physical disorders, especially in the elderly

  • Personality disorders

  • Impulsivity

  • Unemployment and economic downturns

  • Traumatic childhood experiences

  • Family history of suicide and/or mental disorders

Death by suicide is more common among people with a mental disorder than among age- and sex-matched controls.

Some people with schizophrenia die by suicide, sometimes because of depression, to which these people are prone. The suicide method may be bizarre and violent. Attempted suicide among these people is more common than previously thought.

Alcohol and drugs of abuse may increase disinhibition and impulsivity as well as worsen mood—a potentially lethal combination. Between 30% and 40% of people who die by suicide have consumed alcohol before the attempt, and about half of them were intoxicated at the time. Impulsive young men and women are particularly susceptible to alcohol's effects; in them, moderate levels of intoxication can result in their using more lethal suicide methods (1). However, people with an alcohol use disorder are at increased risk of suicide even when they are sober.

Serious physical disorders, especially those that are chronic and painful, contribute to about 20% of suicides in the elderly.

People with personality disorders are prone to suicide—especially emotionally immature people with a borderline or an antisocial personality disorder because they tolerate frustration poorly and react to stress impetuously, with violence and aggression.

Certain social factors (eg, sex partner problems, bullying, recent arrest, trouble with the law) appear to be associated with suicide. Often after such events, suicide is the last resort for these already distressed people.

Traumatic childhood experiences, particularly the stresses of sexual or physical abuse or parental deprivation, are associated with suicide attempts and perhaps completed suicide.

Suicide runs in families, so a family history of suicide, suicide attempts, or mental disorders is associated with an increased risk of suicide in susceptible people.

Etiology reference

  • 1. Park CHK, Yoo SH, Lee J, et al: Impact of acute alcohol consumption on lethality of suicide methods. Compr Psychiatry 75:27–34, 2017. doi: 10.1016/j.comppsych.2017.02.012.

Methods

Choice of method for suicide is determined by many things, including cultural factors and availability as well as the seriousness of intent. Some methods (eg, jumping from heights) make survival virtually impossible, whereas others (eg, drug ingestion) may allow rescue. However, using a method that proves not to be fatal does not necessarily imply that the intent was less serious.

A bizarre method suggests an underlying psychosis.

For suicide attempts, drug ingestion is the most common method used. Violent methods, such as shooting and hanging, are uncommon among attempted suicides.

Almost 50% of completed suicides in the US involve guns; men use this method more than women. Women use poisoning more than men. Other typical methods of suicide include hanging, jumping from a height, drowning, and cutting.

Some methods, such as driving over a cliff, can endanger others.

Management

A health care practitioner who foresees the likelihood of suicide in a patient is, in most jurisdictions, required to inform an empowered agency to intervene. Failure to do so can result in criminal and civil actions. Such patients should not be left alone until they are in a secure environment. They should be transported to a secure environment (often a psychiatric facility) by trained professionals (eg, ambulance, police).

Any suicidal act, regardless of whether it is a gesture or an attempt, must be taken seriously. Every person with a serious self-injury should be evaluated and treated for the physical injury.

If an overdose of a potentially lethal drug is confirmed, immediate steps are taken to prevent absorption and expedite excretion, administer any antidote, and provide supportive treatment (see General Principles of Poisoning : Treatment).

Initial assessment can be done by any health care practitioner trained in the assessment and management of suicidal behavior. However, all patients require psychiatric assessment as soon as possible. A decision must be made as to whether patients need to be admitted and whether involuntary commitment or restraint is necessary. Patients with a psychotic disorder and some with severe depression and an unresolved crisis should be admitted to a psychiatric unit. Patients with manifestations of potentially confounding medical disorders (eg, delirium, seizures, fever) may need to be admitted to a medical unit with appropriate suicide precautions.

After a suicide attempt, the patient may deny any problems because the severe depression that led to the suicidal act may be followed by a short-lived mood elevation. Nonetheless, the risk of later, completed suicide is high unless the patient’s disorder is treated.

Psychiatric assessment identifies some of the problems that contributed to the attempt and helps the physician plan appropriate treatment. It consists of the following:

  • Establishing rapport and listening to the patient's narrative (1)

  • Understanding the suicide attempt, its background, the events preceding it, and the circumstances in which it occurred

  • Inquiring about symptoms of mental disorders that are associated with suicide

  • Fully assessing the patient’s mental state, with particular emphasis on identifying depression, anxiety, agitation, panic attacks, severe insomnia, other mental disorders, and alcohol or drug abuse (many of these problems require specific treatment in addition to crisis intervention)

  • Thoroughly understanding personal and family relationships, which are often pertinent to the suicide attempt

  • Interviewing close family members and friends

  • Inquiring about the presence of a firearm in the house (except in Florida, where such inquiry is forbidden by law)

  • Safety planning to help patients identify triggers to suicidal planning and develop plans to deal with suicidal thoughts when they occur (1, 2),

Management references

  • 1. Michel K, Valach L, Gysin-Maillart A: A novel therapy for people who attempt suicide and why we need new models of suicide. Int J Environ Res Public Health 14 (3), 2017. pii: E243. doi: 10.3390/ijerph14030243.

  • 2. Stanley B, Brown G: Safety planning intervention: A brief intervention to mitigate suicide risk. Cogn Behav Pract 19: 256-264, 2011.

Prevention

Prevention of suicide requires identifying at-risk people (see Table: Risk Factors and Warning Signs for Suicide) and initiating appropriate interventions.

There is consensus that patients who are admitted to the hospital after a suicide attempt are at greatest risk of death by suicide during the first few days or weeks after discharge and the risk remains high during the first 6 to 12 mo after discharge. After that, risk waxes and wanes but is always higher than in people who have never been suicidal.

Reasons for the increased risk of suicide include the following:

  • The patient's mood may take a long time to improve.

  • The patient may not feel optimistic enough to take the prescribed drugs.

  • The patient may not feel good enough to go to the scheduled follow-up appointment.

  • Once at home, the patient feels that the precipitating problems are unresolved.

Consequently, before discharge, the patient and family members or close friend should be counseled about the immediate risk of dying by suicide, and an appointment for follow-up in the first week after discharge should be made before the patient leaves the hospital. In addition, the patient and family members or friend should be told the names, doses, and dose frequency of the patient's drugs.

If possible, during the first weeks after discharge, the following should be done:

  • The patient should not be left alone.

  • The patient's adherence to the prescribed drug regimen should be monitored.

  • The patient should be asked daily about general state of mind, mood, sleep pattern, and energy (eg, for getting up, dressing, and interacting with those around him)

The patient's family member or friend should take the patient to follow-up appointments and should inform the health care practitioner of the patient's progress or lack of it. These interventions should be continued for ≥ 2 mo after discharge.

Risk Factors and Warning Signs for Suicide

Type

Specific Factors

Demographic data

Male

Age 45–64

Social situation

Personally significant anniversaries

Unemployment or financial difficulties, particularly if they caused a drastic fall in economic status

Recent separation, divorce, or widowhood

Recent arrest or trouble with the law

Social isolation with real or imagined unsympathetic attitude of relatives or friends

History of suicidality

Previous suicide attempt

Making detailed suicide plans, taking steps to implement the plan (obtaining a gun or pills), and taking precautions against being discovered

Family history of suicide or a mental disorder

Clinical features

Depressive illness, especially at onset

Marked motor agitation, restlessness, and anxiety with severe insomnia

Marked feelings of guilt, inadequacy, and hopelessness; perception of being a burden to others (burdensomeness); self-denigration; nihilistic delusion

Delusion or near-delusional conviction of a physical disorder (eg, cancer, a heart disorder, sexually transmitted disease) or other delusions (eg, delusions of poverty)

Command hallucinations

Impulsive, hostile personality

A chronic, painful, or disabling physical disorder, especially in formerly healthy patients

Drug use

Alcohol or drug abuse (including abuse of prescription drugs), especially if recent use has increased

Use of drugs that may contribute to suicidal behavior (eg, abruptly stopping paroxetine and certain other antidepressants can result in increased depression and anxiety, which in turn increases risk of suicidal behavior)

Although some attempted or completed suicides are a surprise and shock, even to close relatives and associates, clear warnings may have been given to family members, friends, or health care practitioners. Warnings are often explicit, as when patients actually discuss plans or suddenly write or change a will. However, warnings can be more subtle, as when patients make comments about having nothing to live for or being better off dead.

On average, primary care physicians encounter 6 potentially suicidal people in their practice each year. About 77% of people who die by suicide were seen by a physician within 1 yr before killing themselves, and about 32% had been under the care of a mental health care practitioner during the preceding year.

Because severe and painful physical disorders, substance abuse, and mental disorders (particularly depression) are often a factor in suicide, recognizing these possible factors and initiating appropriate treatment are important contributions a physician can make to suicide prevention.

Each depressed patient should be questioned about thoughts of suicide. The fear that such inquiry may implant the idea of self-destruction is baseless. Inquiry helps the physician obtain a clearer picture of the depth of the depression, encourages constructive discussion, and conveys the physician’s awareness of the patient’s deep despair and hopelessness.

Even people threatening imminent suicide (eg, those who call and declare that they are going to take a lethal dose of a drug or who threaten to jump from a high height) may have some desire to live. The physician or another person to whom they appeal for help must support the desire to live.

Emergency psychiatric aid for suicidal people includes the following:

  • Establishing a relationship and open communication with them

  • Inquiring about current and past psychiatric care and drugs currently being taken

  • Helping sort out the problem that has caused the crisis

  • Offering constructive help with the problem

  • Beginning treatment of the underlying mental disorder

  • Referring them to an appropriate place for follow-up care as soon as possible

  • Discharging low-risk patients in the company of a loved one or a dedicated and understanding friend

  • Providing these patients with the telephone number for Lifeline—1-800-273-TALK (8255)—or with links to the online Lifeline Crisis Chat, Crisis Text Line (text HOME to 741741) or the American Foundation for Suicide Prevention

Treatment of depression and risk of suicide

The combination of antidepressants and some proven short-term psychotherapy is the ideal treatment for depression.

People with depression have a significant risk of suicide and should be carefully monitored for suicidal behaviors and ideation. Risk of suicide may be increased early in the treatment of depression, when psychomotor retardation and indecisiveness have been ameliorated but the depressed mood is only partially lifted. When antidepressants are started or when doses are increased, a few patients experience agitation, anxiety, and increasing depression, which may increase suicidality.

Recent public health warnings about the possible association between use of antidepressants (particularly paroxetine) and suicidal thoughts and attempts in children, adolescents, and young adults have led to a significant reduction (> 30%) in antidepressant prescriptions to these populations. However, youth suicide rates increased by 14% during the same period. Thus, by discouraging drug treatment of depression, these warnings may have temporarily resulted in more, not fewer, deaths by suicide. Together, these findings suggest that the best approach is to encourage treatment, but with appropriate precautions such as

  • Dispensing antidepressants in sublethal amounts

  • More frequent visits early in treatment

  • Giving a clear warning to patients and to family members and significant others to be alert for worsening symptoms or suicidal ideation

  • Instructing patients, family members, and significant others to immediately call the prescribing clinician or seek care elsewhere if symptoms worsen or suicidal ideation occurs

Several studies have shown that lithium, when given with antidepressants and atypical antipsychotics, reduces the number of deaths by suicide in patients with major depression or bipolar disorder. Lithium, even in low doses, is highly effective as an antisuicidal drug for recurrent depression. In addition, clozapine reduces suicide risk in patients with schizophrenia.

Electroconvulsive therapy is still used for the treatment of severe depression and for suicidal depression.

Effect of Suicide

Any suicidal act has a marked emotional effect on all involved. The physician, family members, and friends may feel guilt, shame, and remorse at not having prevented a suicide, as well as anger toward the deceased or others. The physician can provide valuable assistance to the deceased’s family members and friends in dealing with their feelings of guilt and sorrow.

Physician Aid in Dying

Physician aid in dying (formerly, assisted suicide) refers to the assistance given by physicians to people who wish to end their life. It is controversial and is legal in only 5 US states (Oregon, Washington, Montana, Vermont, California) and in Canada; all states where physician aid in dying is legal have guidelines for participating patients and physicians, such as eligibility and reporting requirements (eg, the patient must be mentally competent and have a terminal illness with a life expectancy of < 6 mo). Voluntary euthanasia is legal in the Netherlands, Belgium, Columbia, and Luxembourg. Assisted suicide is legal in Switzerland, Germany, Japan, and Canada.

Physician-assisted suicide (or assisted death) involves making lethal means available to the patient to be used at a time of the patient’s own choosing. In voluntary active euthanasia, the physician takes an active role in carrying out the patient’s request; it usually involves IV adminstration of a lethal substance.)

Despite the limited availability of physician aid in dying, patients with painful, debilitating, and untreatable conditions may initiate a discussion about it with a physician.

Physician aid in dying may pose difficult ethical issues for physicians.

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