Risk Factors Suicide

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Suicidality and Suicide in Primary Care: Introduction

In those with major depression, the risk for suicide is increased 20-fold

compared with the general population.[1] A history of major depression is

present in about 60% of those who complete suicides. An estimated 8% ofthose with major depression attempt suicide at some time during their

lifetime. This rate is increased in those with comorbid anxiety disorders (eg,

25% with comorbid panic disorder and 38% in those with comorbid

posttraumatic stress syndrome disorder).[2] About 31,000 people in the

United States and 1 million worldwide die by suicide each year, and

650,000 people in the United States are treated emergently following a

suicide attempt

Should You Ask About Suicidal Ideation?

Physicians might be hesitant to inquire about suicidal thoughts, worried

that inquiry might lead to suicide attempts. However, this has not been

demonstrated. In contrast, patients with such thoughts often seek the

opportunity to discuss them, but may not verbalize their concerns without

being prompted. The initiation of an office visit might be the only clue of

suicidality. Although patients may be reluctant to divulge their intent to

commit suicide, if asked, patients with suicidal ideation usually will tell their

physicians about such thoughts.[4]

Recognizing the suicidal patient can be a challenge in primary care settings.

No studies have demonstrated that screening for suicidality in primary care

settings reduces completed suicides or attempts.[5] Depression screening

and severity assessment instruments such as the Patient Health

Questionnaire (PHQ)-9 and Quick Inventory of Depressive Symptomatology

(QIDS) include questions about suicidal ideation ("Thought that you wouldbe better off dead or hurting yourself in some way?") that can trigger

further inquiry by the physician. However, because we do not have

instruments that adequately predict which patients with suicidal thoughts

will attempt suicide, once they are recognized, further inquiry and

physician judgment should determine any intervention


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Risk Factors: What to Look Out For

An understanding of the risk factors for suicide can facilitate the

recognition of high risk patients, and help in their assessment. Patient

characteristics that increase suicide risk include:

Past attempts: Half of suicide completers attempted suicide previously and

1 out of 100 suicide attempt survivors die by suicide within the next year, a

risk 100-fold greater than that in the general population.[6]

Psychiatric: Patients with multiple psychiatric conditions appear to be at

higher risk than those with uncomplicated depression or an anxiety

disorder.[7] Psychiatric disorders most frequently associated with suicide

include depression, bipolar disorder, alcoholism or other substance abuse,

schizophrenia, personality disorders, anxiety disorders (including panic

disorder), posttraumatic stress disorders, and delirium.[8,9] Anxiety

disorders double risk for suicide attempt (odds ratio = 2.2)[10] but a

combination of depression and anxiety greatly increases the risk (odds ratio

= 17).[9] In depressed patients, comorbid personality disorder also

correlates strongly with suicide attempts. In addition, 20% to 25% of suicide

completers are intoxicated at the time.[3]

Age, sex, and race: Although young adults attempt suicide more often than

older adults, the risk for completed suicide increases with age.[11] Men are

3 times more likely to complete suicide, although women attempt suicide 4

times more often than men.[12] These differences are the result of the

lethality of the chosen method (eg, firearms) more than to a difference

across age or sex in completion rates for a particular method.[13] White

people complete about 90% of suicides in the United States; 72% are by

white men.

Work status: Unemployed and unskilled individuals are at increased risk

compared to those employed and skilled; occupational failure may lead to

higher risk. Physicians, particularly female physicians, may be at increased

risk; a 25-study meta-analysis yielded a suicide rate ratio for female


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physicians of 2.3 and for male physicians of 1.4 compared with the general

population.[14]

Impulsivity: Impulsivity increases the likelihood of acting on suicidal

thoughts, and the combination of hopelessness, impulsivity, and substanceabuse-related disinhibition may be particularly lethal.[3] This combination

occurs most frequently in young adults.

Health: Medical illness, including chronic pain, chronic disease, and recent

surgery increases suicide risk.[3] HIV infection by itself does not increase

risk.[15]

Family factors:Having a first-degree relative who committed suicide

increases risk sixfold. The heritability of suicide is in the 30% to 50% range,

although it is uncertain whether genetic makeup contributes to the

underlying psychiatric disorder or to the suicide itself.[3] Individuals who

have never married are at the highest risk for completed suicide, followed

in descending order by those who are widowed, separated, or divorced;

married without children; and married with children. Risk also increases in

patients who live alone, who have lost a loved one, or who have

experienced a failed relationship within one year.[16] The anniversary of a

significant loss is also a time of increased risk. Having a spouse who

committed suicide increases the risk for suicide in the survivor.[17]

Abuse and other adverse childhood experiences increase the risk for suicide

in adults, at least partially mediated by the presence of alcoholism,

depression, and illicit drug use, which also are strongly associated with

adverse events in childhood.[3]

Access to means: Of all suicides in the United States, 57% -- and 62% in

men -- are caused by a firearm, with rates increased 4- to 10-fold in

adolescents who live in a household with a gun.[18] The second leading

methods of suicide in the United States are hanging for men and poisoning

for women.


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Hopelessness: Hopelessness is a concept that may contribute to suicide,

independent of depression. One multivariate analysis found hopelessness

to be 1.3 times more important than depression in explaining suicidal

ideation.[19] It may mediate the relationships between interpersonal

losses, loneliness, low self-esteem, and suicide. Those in whom

hopelessness persists when depression has remitted continue to be at high

risk for suicide.[3]

Protective factors: Family connectedness and social support are protective.

Family discord increases the risk for suicide.[3] Parenthood, particularly for

mothers, and pregnancy decrease the risk for suicide.[20] Participating in

religious activities and religiosity are associated with a lower risk for

suicide.

Knowledge of the above risks and protective factors can be used in

assessing patients for whom suicide risk is a concern

I've Detected Risk Factors: Now What?

Once the potential for suicide is recognized in a patient (for instance by

positive response to the suicidality question on the PHQ-9), the next step in

its management is to evaluate the presence, frequency, and duration of

suicidal thoughts; their intensity and content; any changes in chronic

thoughts; and whether or how the patient has been controlling these

thoughts. Inquiry might start by asking whether the patients feels he or she

would be better off dead, whether he or she has lost interest in living, or

whether the patient has thought of ending his or her life. Inquiring about

expectations from death may be useful. This might reveal motivations, such

as reuniting with a loved one, punishing others, or escaping a painful

situation.

Probing the patient's suicide plan can be helpful in assessing the severity of

intent. Questions of interest include:


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Has a plan been formulated or implemented, including a specific method,

place, and time?

Have preparations been made (eg, gathering pills, changing wills, suicide

notes)?

Has the patient practiced the suicidal act or has an actual attempt already

been made?

What is the anticipated outcome of the plan?

Are the means of committing suicide available?

Does the patient know how to use these means?

What is the plan's lethality?

What is the patient's conception of lethality vs the objective lethality?

What is the likelihood of rescue?

What is the strength of the intent to carry out suicidal thoughts and plans,

including the ability to control impulsivity?

Further inquiry should seek to identify any precipitating events, such as thedeath of a loved one; breakup of a marriage; work, school, or social failure;

sexual identity crisis; or trauma. Determining the patient's sense of

hopelessness ("what the future looks like") and any alcohol and substance

abuse history, including binging, impulsivity, and family and social supports

or stressors, may be helpful in selecting an appropriate management plan.

Other important factors include whether the patient is engaged in and

complying with treatment, recent stressors that might threaten the

patient's ability to cope with difficulties and ability to participate in

treatment planning, and any previous suicide attempts.


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How To Manage Risk Factors

Using the aforementioned information, the risk for suicide should be

estimated and managed accordingly:

Imminent (eg, suicide might be attempted within the next 48 hours):

Patients have an active plan or intent to harm themselves and have a lethal

means readily accessible. Also at high risk are those who are psychotic

(especially if they hear voices telling them to commit suicide), those who

are cognitively impaired, or those who lack judgment. Such patients usually

require immediate hospitalization via ambulance. In such individuals, and

especially in those with no immediate supports, electroconvulsive therapy

may be lifesaving.[3]

High but not imminent (eg, those with a desire to commit suicide but who

do not have a specific plan): This group needs aggressive treatment, but not

necessarily hospitalization. Interventions might include psychiatric

treatment; control of substance use; mobilizing family and social supports;

reducing access to firearms, medications, or other potentially lethal means;

and ensuring frequent contact with helping professionals and supports.

Contributing factors should be addressed, including precipitating events,

ongoing life difficulties, and comorbid mental disorders.

Although contracting for safety has not been evaluated adequately, there is

little evidence that it is effective. Consequently, such "contracts" may

provide a false sense of security.[3] Maintaining a strong therapeutic

alliance and direct communication and providing frequent re-evaluation are

recommended. Supportive primary care counseling; referral for

psychotherapy; and engagement of community, religious, and family

supports can be helpful. Of note, cognitive-behavioral therapy might beparticularly helpful in those in whom hopelessness is a concern.

Although the suicidality warning is present on the label of most

antidepressants, this should be viewed as a reminder to educate and

frequently re-evaluate patients in whom depression and suicidality are


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present. It should not be taken as a warning not to use antidepressants in

such patients. The United States experienced a 91% increase in

antidepressant prescriptions, accompanied by a 33% decline in completed

suicide during the 5 years (1998-2003) preceding the addition of the

warnings. The Netherlands had similar experience.[21] Warnings about a

possible association between antidepressant use and suicidal thinking and

behavior were issued by the US Food and Drug Administration and by

several European regulators in 2003. This resulted in a 22% decrease in

selective serotonin reuptake inhibitor prescriptions for youths in both the

United States and The Netherlands and a resultant 14% increase in

completed suicide in the United States (2003-2004) and a 49% increase in

The Netherlands (2003-2005).[21] Therefore, antidepressants should not be

avoided because of the concern that they might infrequently heighten

suicidal thoughts.

The primary care physician should maintain regular follow-up contact with

patients identified as at risk for suicide. Suicide risk fluctuates and should

be reevaluated frequently. As part of monitoring previous suicidal patients,

the clinician should determine whether there have been changes, such as a

reemergence of precipitating events, adverse life circumstances, or

worsening of mental disorders. Continued participation in interventions

and treatment should be monitored.

The importance of primary care in reducing suicide is clear. Of patients who

commit suicide, 75% had contact with their primary care clinician during

the year before their death, compared with one third who had contact with

mental health services. In the month before death, twice as many of those

who commit suicide had contact with primary care providers as with

mental health services (45% vs 20%).

Risk Factors Suicide

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