Suicidal Behavior

Background and Importance

Emergency clinicians care for many patients with suicidal ideation and self-harm behaviors. Two facts are especially important to remember in the care of suicidal patients. First, many suicide attempts occur during an acute crisis, such as a personal loss or the exacerbation of an underlying psychiatric disorder. This acute crisis is usually time-limited and is often resolvable or treatable. Second, suicidal patients are usually ambivalent about dying and grateful for help. An empathetic, patient-centered, and evidence-based approach by emergency care providers offers the opportunity to save lives.

Medical literature contains numerous terms to describe different types and degrees of suicidal thoughts and behaviors. Suicidal behavior refers to any observable mental state or outward behavior related to ending one’s life. Suicidal ideation refers to thoughts of killing oneself. Suicidal intent refers to the desire to proceed with suicide. A suicidal plan refers to a conceived specific method in which a person would attempt suicide, such as by firearm, hanging, poisoning/overdose, or cutting oneself. Lethal means refers to someone having accessibility to a method in which to carry out a suicidal plan, for example, having physical possession of a firearm. A suicide attempt is a self-directed act with the intent to die. Non-suicidal self-injury (NSSI) is an intentional act of self-harm without the intent to die as a result of the behavior. Terms to avoid because of implicit value judgement of a derogatory nature include committed or successful suicide, suicidal gesture, manipulative act, and suicide threat.

Epidemiology

Suicide was the tenth leading cause of death in the United States in 2017. It is the second leading cause of death for people 10 to 34 years of age, the fourth leading cause among people 35 to 54 years of age, and the eighth leading cause among people 55 to 64 years of age. There were more than one million suicide attempts and 47,000 suicide deaths in the United States in 2017, and rates continue to rise. ^, It is estimated that in 2017 there were almost 500,000 visits to emergency departments (EDs) nationally for intentional nonfatal injuries. ^,

Contrary to popular belief, the majority of individuals (54%) in the United States who die by suicide do not have a known mental illness at the time of death; these individuals are much more likely to be male (84%) and to die by firearm (55%). Of the individuals who die with known mental health conditions, the majority are still male (69%) and more likely to die by firearm (41%) or suffocation (31%). Although women make up a higher proportion of suicide attempts, men are more likely to die by suicide due to use of more lethal methods.

The ED plays a critical role in acute stabilization and initiation of appropriate preventative efforts to reduce subsequent suicide mortality. ^, It is estimated that 1 in 5 suicide fatalities are seen in an ED in the month prior to their death, which suggests 9,000 suicide deaths each year could be reduced through improved ED suicide prevention efforts. An empathic, patient-centered, and evidence-based approach offers the opportunity to save lives.

Risk Factors

Pathophysiology

The etiology of a suicide attempt is a complex mix of social, genetic, and psychological factors, what psychiatrists would refer to as a “bio-psycho-social” model. Several genetic and neurobiological factors have been proposed as contributors to suicide risk, including abnormalities in the serotonin transport system, the stress response systems (hypothalamic–pituitary–adrenal (HPA) axis and polyamine system), neuroinflammation, and lipid metabolism. Psychological factors associated with the highest suicide risk are hopelessness and impulsivity.

The social contributions to risk of suicide have perhaps the most immediate, temporal relationship with suicide attempts. Many of the most prevalent precipitating factors associated with suicide occur in the social domain, namely relationship problems, recent crises, financial problems, criminal or legal problems, and homelessness. There is a growing body of evidence suggesting that adverse childhood experiences are strong risk factors for future suicide that affect individuals on biological, psychological, and social levels. ^{, ,}

Methods of Suicide

Firearms account for half of all deaths from suicide for patients with and without mental illness, as this is the most lethal method with little to no opportunity for the individual to experience regret or ask for help. There is a well-established relationship between the presence of a firearm in the home and higher rates of suicide. ^,

The next most lethal method is hanging or suffocation (25%), followed by poisoning or overdose (16%). Overdose and poisoning attempts are relatively common, and account for over two-thirds of ED visits for suicide attempt or self-harm. Intentional overdose is particularly common among adolescents; 63% of all overdoses for patients ages 13 to 19 years were intentional. These attempts are less frequently lethal due to delayed lethality from absorption, ability for the individual to express regret and ask for help, and opportunities for emergent treatment once help is obtained. Death by suicide from overdose is most commonly due to opioids, although it is often difficult in public health records to distinguish death by suicide from deaths due to unintentional overdose, abuse, or misuse. Children and adolescents use whatever is readily available, such as commonly used over-the-counter medications like acetaminophen and ibuprofen, which can be quite lethal or lead to severe complications.

Initial Recognition and Screening

Due to stigma and fear of repercussions, patients who present to the ED following a traumatic event may not disclose the cause of their injury was a suicide attempt. The potential for suicide should be considered in patients who present with unintentional overdose or accidental gunshot wounds, lacerated wrists, automobile crashes, or falls from heights. Patients who are not overtly suicidal but who exhibit one or more of these high-risk presentations require assessment in an empathic but direct manner using a “graduated” approach. Rapport can first be established during a general medical and psychiatric history, with an evaluation of the patient’s home, work, and social situation, followed by specific questions about recent psychosocial stressors, signs and symptoms of depression, and the presence of suicidal thoughts. Such questioning does not cause a person to consider suicide who has not already been considering it. This approach can be described as indicated screening of those with acute risk factors.

A more systematic screening approach would be selective screening of all patients in high-risk groups, such as those with chronic risk factors for suicide including prior suicide attempts or mental illness. Universal screening for suicidal risk involves questioning all patients about suicidal thoughts or behaviors. Universal screening is supported by evidence suggesting that approximately 10% of all ED patients have recent suicidal ideation or behaviors, and 40% of suicide victims have visited an ED within the prior year. For ideal functioning, any screening program can be integrated into available electronic medical records and work flow to optimize efficiency, increase provider uptake, and maximize impact. ^,