At his wife’s urging, Mr. L, age 34, presents to the local emergency room (ER). Approximately 1 week ago, he woke up in the middle of the night and told her he was afraid he would die because he had heart palpitations, a choking sensation, dizziness, and shortness of breath.
The ER physician rules out an acute medical illness and requests a psychiatric consultation. Mr. L is reluctant to talk to the psychiatrist, saying he has just had a difficult couple of weeks because of problems at work. With Mr. L’s permission, the psychiatrist speaks with his wife and learns that for several weeks Mr. L has been having problems falling asleep and has been waking up early. Mrs. L noticed her husband is unable to sit still, not enjoying his favorite television shows, and drinking more alcohol at night.
The clinical picture became clearer after Mr. L tells the psychiatrist that approximately 1 month ago, he lost his appetite, had low energy and concentration, and began to feel depressed. He denies having suicidal thoughts or plans, but says his suffering is increasing and he doesn’t know what to do.
Suicide is our worst outcome; at times it can seem like we are helpless to change its frequency or evaluate its likelihood. As clinicians, we are not expected to predict who will commit suicide, but are expected to perform an adequate suicide risk assessment and determine who is at high risk. We need to clearly document a patient’s suicide risk level in his or her chart, and our subsequent actions need to be consistent with that assessment. For instance, arranging for additional supports—including psychiatric hospitalization when necessary—for a patient deemed to be at high risk for suicide is considered the standard of care. In this article, I:
- discuss demographic factors related to suicide
- explore the importance of time-related suicide risk factors and the few treatments shown to reduce suicide risk
- review protective and preventive factors.
Sobering statistics
Over the past decade, suicide rates in the United States have remained fixed at slightly more than 30,000 per year. In 2009—the most recent year for which statistics are available from the Centers for Disease Control and Prevention—there were 36,547 suicides in the United States, making it the 10th leading cause of death.1 The rates of suicide completions and attempts vary by sex and age. Males complete suicide 4 times more often than females, whereas females attempt suicide 3 times more often. Among individuals age 15 to 24, 86% of those who completed suicide were male; in older persons (age >65), 85% were male.2 Although rates of completed suicide are highest among older adults, rates of suicide attempts are greatest among young persons. The ratio of attempted-to-completed suicide is 100 to 200:1 in individuals age 15 to 24 but 4:1 in those age >65.2
Whites and Native Americans have the highest suicide rates (12.3 and 12.9 per 100,000, respectively).2 Guns are the most common method of completed suicide in all age groups in the United States: they are used in 53% of all suicides and 76% of those among persons age >70.3 In >90% of completed suicides, the decedent had been diagnosed with ≥1 psychiatric disorder.3 By far, the most common psychiatric illness is major depressive disorder, present in 75% of those who commit suicide.3
Understanding intent
Many physicians believe that patients will tell them if they are feeling worse and are starting to think more seriously about suicide. There is no better example of this than the “contract for safety” or “no-harm contract,” in which a patient signs a paper agreeing to notify a clinician if he begins to develop more intense suicidal feelings. Studies have shown that these “no-harm contracts” do not prevent suicide; this makes sense because if a patient decides to kill himself, telling a clinician puts up an obstacle.4-6
Patients who commit suicide often communicate their suicidal intent, but usually tell family members rather than clinicians. In 1 study, 78% of patients who committed suicide on an inpatient unit denied suicidal ideation at their last communication with staff; although 60% told their spouse and 50% told other relatives, only 18% told their physician.7 In this study, precautions provided a false sense of security: 51% of patients were receiving 15-minute suicide checks or 1-to-1 observation at the time of suicide.7
Who is at risk?
The most recent American Psychiatric Association Task Force Report on Suicide identified 57 risk factors for suicide.8,9 This has led to confusion among clinicians and may have led some clinicians to repeatedly ask patients about suicidal ideation rather than conduct a suicide risk assessment.