Care of the Suicidal Patient

Epidemiology

Suicide accounts for 1.6% of the total number of deaths in the United States each year. Although no nationwide data on annual attempted suicides are available, research indicates that for every completed suicide, approximately 10 to 40 attempts are made; of note, some individuals make more than one unsuccessful attempt. Each year, EDs treat nearly 800,000 self-inflicted injuries or suicide attempters. These visits represent approximately 1.9% of all annual ED visits. Recent trends suggest that after a period of decline in suicide rates in the United States from 1986 to 1999, suicide rates have increased almost steadily between 1999 and 2014, with greater annual percentage increases after 2006. 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. 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 11,400 suicide deaths per year. 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 6800 deaths per year. However, between 1999 and 2014, the percentages of suicides involving firearms and poisoning declined, while suicides involving suffocation increased. Historically, drug ingestion has accounted for the majority of unsuccessful suicide attempts.

Suicide rates differ by age, gender, and race. Rates generally increase with age; people older than 65 years are 1.5 times more likely to commit suicide than are younger individuals, whereas white men over age 85 years have an even higher rate of suicide. 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. Although the elderly have the highest suicide rates, suicide in young adults (between the ages of 15 and 24) rose three-fold between 1950 and 1990, becoming the third leading cause of death following unintentional injuries and homicide. From 1990 to 2003, the suicide rate declined in the 10- to 24-year-old age group. However, in 2004, for the first time in a decade and a half, the suicide rate in this age group increased by 8%. In addition, hanging/suffocation became the most common method of suicide among girls in this age group. Since 2008, the rate of suicide in this population has continued to increase. In females, the largest percentage increase in suicide rates between 1999–2014 was in the 10 to 14 age group, increasing by 200%.

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, although women are three to four times more likely than men to attempt suicide. The reasons for these disparities have not been established clearly. Whites and Native Americans attempt and commit suicide more than non-whites. African Americans and Hispanics have approximately half the suicide rate of whites.

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 and with the vast majority of attempted suicides. 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% ( Table 44-2 ).

Up to 15% of patients with MDD or bipolar disorder complete suicide, almost always during depressive episodes; this represents a suicide risk 30 times greater than that of the general population. True life-time risk may be somewhat lower, because these estimates (and those for the other diagnoses discussed later) typically are derived from hospitalized patient samples. The risk appears to be greater early in the course of a life-time disorder, early on in a depressive episode, in the first week following psychiatric hospitalization, in the first month following hospital discharge, and in the early stages of recovery. The risk may or may not be elevated by co-morbid psychosis. A 10-year follow-up study of almost 1000 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. A study of 667 patients with MDD found that patients who reported prior suicide attempts had more current general medical conditions, more current alcohol or other substance abuse, more work hours missed in the past week than non-attempters, and also reported more current suicidal ideation.

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

Nearly 20% of people who complete suicide are legally intoxicated at the time of their death. 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. Use of alcohol and drugs may impair judgment and foster impulsivity.

Approximately 10% of patients with schizophrenia complete suicide, mostly during periods of improvement after relapse or during periods of depression. The risk for suicide appears to be greater among young men who are newly diagnosed, 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. The risk may also be increased with akathisia and with abrupt discontinuation of neuroleptics. 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.

Between 4% and 10% of patients with borderline personality disorder and 5% of patients with antisocial personality disorder commit suicide. The risk appears to be greater for those with co-morbid unipolar depression or alcohol abuse. 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. A prospective cohort study of 7968 patients examined suicide rates up to 4 years after a deliberate self-harm episode and found an approximately 30-fold increase in risk of suicide compared to the general population.

As many as 15% to 20% of patients with anxiety disorders complete suicide, and up to 20% of patients with panic disorder attempt suicide. 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. The risk for suicide attempts may be elevated for women with an early onset and with co-morbid alcohol or drug abuse. Patients with obsessive–compulsive disorder (OCD) have also been found to be at high risk for suicidal behavior, with a history of suicide attempt reported in 27% of subjects in one study.

The first prospective study of body dysmorphic disorder (BDD) found that patients with BDD have rates of suicidal ideation that are approximately 10 to 25 times higher than those in the general population and that their suicide attempt rate was 3 to 12 times higher. The completed suicide rate of patients with BDD is still being studied.

One study of 754 inpatients and 1100 patients assessed following discharge from a psychiatric inpatient unit found that nearly a quarter of the inpatient suicides occurred within the first 7 days of admission—the majority died by hanging. Post-discharge suicide was most frequent in the first 2 weeks after leaving the hospital, with the highest number of deaths occurring on the first day following discharge.