Suicide

Suicide refers to the act of intentionally ending one's own life. If that action fails, it is called a suicide attempt. Suicide and suicide attempts are more broadly considered suicidal behavior. By definition, suicidal behavior requires both general thoughts about suicide and concrete, deliberate plans to act upon those ideas (suicidal ideation). While suicidal ideation can precede suicide and, therefore, should be investigated thoroughly, it often occurs independently of any suicidal behavior. While attempted suicide is more common in women, completed suicide is significantly more common in men. Suicidal ideation is often associated with psychiatric illness (e.g., major depressive disorder, bipolar disorder). The most important diagnostic step is the evaluation of possible suicidal ideation and prior suicide attempts. Acute management is focused on stabilization and preventing imminent acts of suicide (e.g., by admitting the patient to a psychiatric institution). After there is no longer an immediate risk of self-harm, underlying conditions and risk factors must be addressed (e.g., with treatment with antidepressants). Frequent follow-ups beginning soon after initial treatment are vital for preventing the recurrence of suicidal behavior.

• Suicidality: a state describing either suicidal ideation, suicide plans, or suicide attempts.
• Suicidal behavior: includes suicide attempts and completed suicide
  • Suicide: the act of intentionally ending one's own life
  • Suicide attempt: a potentially injurious behavior intended to end one's own life that does not result in a lethal outcome
• Suicidal ideation
  • Any thoughts of or plans to intentionally end one's own life that do not include preparatory behavior
  • Suicidal ideation and behavior are often present simultaneously. ^[1][2][3]

Suicide

• Incidence ^[4]
  • There are ∼ 47,000 suicides every year in the US.
  • Suicide is the 10^th leading cause of death for all ages and the 2^nd leading cause in individuals 15–34 years of age.
• Age
  • Peak incidence: 45–64 years
  • Incidence significantly increases after age 15, with another significant increase after age 45. ^[4]
• Sex: ♂ > ♀ ^[5]
• Method: > 50% of suicides are by firearm. ^[6]

Suicide attempts

• Incidence ^[7]
  • > 1 million suicide attempts per year
  • ∼ 25 suicide attempts per suicide
• Age: Peak incidence is 15–19 years. ^[7]
• Sex: ♀ > ♂ ^[5]

Completed suicides are more common in men, while suicide attempts are more common in women. ^[8]

Epidemiological data refers to the US, unless otherwise specified.

Risk factors for suicidal behavior ^[9][10][11]

• Previous suicide attempt (most important risk factor)
• Psychiatric disorders
  • Psychosis
  • Schizophrenia
  • Mood disorders
    • Major depressive disorder
    • Bipolar disorder
  • Alcohol or substance use disorder
  • Eating disorders
• Recent psychiatric hospitalization
• History of aggressive behavior
• Other chronic and/or serious diseases (e.g., cancer or chronic pain)
• Age > 45 years
• Male sex: ↑ risk of completed suicide
• Family member that died by suicide
• Social factors: unemployment, no spouse, poor social support/few social contacts, early loss of a parent
• Access to and/or possession of firearms: ↑ risk of completed suicide
• Socioeconomic status (refugees, homeless persons)
• History of sexual assault

SAD PERSONS are at risk for suicide: Sex (male), Age (> 45 years), Depression, Previous suicide attempt, Ethanol/substance use, Rational thinking loss (psychosis), Sick (chronic disease), Organized plan (acquisition of weapons/tools), No spouse or social support, Stated intent.

General psychiatric evaluation ^[9][11]

• Ask specifically and directly about suicidal ideation and concrete intent/plans.
  • Helps evaluate the imminent risk of suicide (i.e., need for hospitalization)
  • Allows for assessment of whether the patient is in a position to act on their plans (e.g., possession of firearms)
  • Inform the patient that patient confidentiality may be breached if there is clear evidence of imminent danger or harm to the patient or others.
• Investigate potential underlying conditions (e.g., mood disorders, schizophrenia, substance abuse, recent severe psychological stress/trauma).
• Ask about previous suicide attempts (also within the family), feelings of despair, and ambivalence towards death.
• If previously depressed and agitated patients suddenly become calm or less symptomatic, the risk of suicidal behavior increases.

Further diagnostics

• 5-Hydroxyindoleacetic acid (5-HIAA): low 5-HIAA in CSF correlate with suicide attempts in patients with mood disorders (especially following prior suicide attempts) ^[12][13]

Sudden improvement of symptoms in depressed patients (e.g., a normally agitated patient who is calm) may indicate an imminent suicide plan.

If there is any reason to suspect suicidal ideation, ask the patient about it.

Nonsuicidal self-injury (NSSI) ^[14]

• Definition: a pattern/any form of intentional self-injury to the surface of the body (e.g., cutting, burning, excessive scratching) without suicidal intent
• Epidemiology ^[15]
  • Most commonly seen in adolescents (approx. 18% worldwide)
  • Increased prevalence in child and adolescent psychiatric inpatients (around 50%)
• Etiology
  • Individual factors (e.g., psychiatric conditions such as borderline personality disorder and eating disorders and/or emotional dysregulation)
  • Environmental factors (e.g., childhood maltreatment, disruption of attachment)
• Clinical features
  • Depend on the type of self-injury (e.g., cutting, burning)
  • Patterns of scars from previous self-injuries (e.g., parallel cutting or grouped cigarette-burn scars)
  • Patients may present with acute injuries
• Diagnosis: clinical
• Differential diagnoses: sexual violence, intimate partner violence, elder abuse
• Treatment
  • In acute NSSI: depending on the type of self-injury, surgical treatment might be necessary (e.g., stitches)
  • Indications for psychotherapy include:
    • Several episodes of NSSI or a single episode, which was done to cope with distress and/or required medical attention
    • Visible characteristic signs of NSSI (e.g., a pattern of characteristic parallel scars on arms and/or thighs)
  • In pediatric patients, physicians may respect the patient's wish to not inform parents if the child's safety is not at risk; i.e., if the self-injury does not suggest a behavioral pattern (e.g., a single episode), the injury is nonsevere, and there is no suicidal ideation.
  • Literature on the treatment of NSSI remains scarce, but the following interventions and factors have proven beneficial: ^[16]
    • Early detection to prevent self-injurious behavior from becoming entrenched
    • Thorough assessment of the patient to identify underlying causes (e.g., depression, PTSD) for which NSSI functions as a coping mechanism
    • Collaborative therapeutic setting that focuses on motivation for change and addresses NSSI behaviors directly
    • Cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), cognitive analytic therapy (CAT), and mentalization-based treatment (MBT)
    • Education on and training in cognitive and behavioral techniques, emotional regulation, and problem-solving skills for coping with distress
    • Safety contracts and other risk management measures
  • The following interventions may be beneficial:
    • Family involvement in the course of treatment
    • Pharmacotherapy with drugs targeting the serotonergic, dopaminergic, and opioid systems

The differential diagnoses listed here are not exhaustive.

Acute management ^[11]

Imminent risk of suicidal behavior ^[9]

The risk of suicide is imminent if suicidal ideation, intent, and a concrete plan are present.

• Goal: : risk reduction by actively preventing the patient from suicidal behavior and assuring the patient's safety
• Approach
  • Hospitalization: preferably admission to a psychiatric unit
    • Ideally, the patient is admitted to the hospital voluntarily.
    • Against the patient's will if the patient is uncooperative and in immediate danger of self-harm
  • Remove hazardous objects from the patient's environment that could be used in a suicide attempt (e.g., remove firearms from home).
  • Do not leave the patient alone or even with his or her family.
  • If necessary, involve the authorities (e.g., local police).
• Special patient group: If minors are hospitalized due to an imminent risk of suicidal behavior, their parents must be informed; however, parental (or legal guardian) consent for such action is not required.

Elevated risk of suicidal behavior

The risk of suicide is elevated if there is suicidal ideation and intent but no concrete plan is present.

• Approach
  • Involve the family of the patient and inquire about the patient's psychological and social situation (e.g., history of suicidal ideation, access to firearms, social connections).
  • Take measures to increase the patient's social contacts and interaction with medical professionals.

Long-term management

• Treatment of underlying psychiatric disorders
  • Pharmacological therapy
    • Mood stabilizers: Lithium is an effective mood stabilizer in suicidal patients with major depressive disorder. ^[17]
    • Antidepressants
      • SSRIs; (and other antidepressants): can initially cause increased activity, which may lead to increased suicidal behavior; in adolescents, especially within the first few weeks of treatment ^[18]
      • Tricyclic antidepressants, MAO-inhibitors, venlafaxine: Avoid if possible, since lethal overdoses can occur relatively easily with these medications.
    • Antipsychotics
  • Electroconvulsive therapy: used for major depressive disorder and bipolar disorder that does not respond to other treatments.
• Counseling
  • Improvement of social circumstances; that constitute risk factors for suicidal behavior (e.g., changing living conditions and increasing social contacts and a sense of connectedness)
  • Development of; personal skills that have a protective effect (e.g., problem-solving and coping skills; ) and encouraging reflection about religious and/or cultural beliefs to promote a sense of purpose.

If antidepressants such as SSRIs are given, the increase in energy and motivation occurs sooner than the improvement in mood. Therefore, suicide risk may increase during the first weeks of treatment. Close observation and frequent follow-ups are vital!

If there is any evidence of suicidal ideation, all firearms should be removed from the patient's home!

Any patient with the intent to act on a concrete suicide plan should be hospitalized immediately!

• Risk of suicide is generally increased in the following settings:
  • After previous suicide attempt(s)
  • During the first weeks following discharge from psychiatric care
  • During recovery from severe depression
• To prevent suicide, regular follow-ups should occur:
  • Soon after discharge (ideally within 7 days) ^[19]
  • Frequently (vital for long-term outcome) ^[9][20]

• One-Minute Telegram 61-2022-3/3: Fluoroquinolones are not associated with increased suicidality
• One-Minute Telegram 4-2020-2/3: The other epidemic: handgun ownership and suicidality

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