Psychiatry

Suicide Risk Assessment

Background

1. Definition
   • Suicide: One's attraction to kill himself
2. General Information
   • Very common among psychiatric patients
   • Risk of suicidality is should NEVER be considered zero
   • Previous attempt to commit suicide is the single most important risk factor to complete a suicide
   • Most common methods of suicide
     • Ingestion (e.g., pesticides, prescription drugs)
     • Hanging
     • Firearms
   • Suicide is not always preventable, even with good clinician assessment and management
3. Epidemiology
   • Incidence/Prevalence
     • Suicide is the 10th leading cause of death in the US
       • Rate = 12/100,000 per year (25,000 deaths/year)
       • 3rd leading cause of death for children, adolescents and young adults
     • In the US 2014, there were 42,773 suicides
     • Females attempt suicide 3 times as often as males
       • Males complete suicide 3 times as often as females
     • Risk of 2nd attempt is highest within the first 3 months following 1st attempt
   • Morbidity/Mortality
     • Worldwide there are close to 800,000 suicide deaths yearly
       • The second leading cause of death between 15-29 years of age
       • Around 79% occur in low and middle socioeconomic class
     • Approximately 1/10 attempts successful

Pathophysiology

1. Etiology
   • Increased diathesis of serious suicide attempts and completed suicides
2. Risk factors for suicide
   • Depressive disorders
   • Severe Anxiety
   • PTSD
   • Schizophrenia
   • Bipolar disorder
   • Personality disorders (e.g., borderline personality)
   • Alcoholism
   • Substance abuse
   • Prior suicide threats and/or attempts (see suicide ideation scale)
   • Male sex
   • Age: > 65 years old (peak incidence: males = 75 years old; females = 60 years old)
   • Family history
   • Never married, widowed, or divorced
   • Chronic illness or pain
   • White or Native American
   • Firearms access
   • Unemployed

Diagnostics

1. History/Symptoms
   • PMH
     • Family history of suicidality
     • Social history (e.g., substance abuse/ dependence, alcoholism, STDs, work)
     • SAD PERSON'S score (see SAD PERSON'S scale)
       • S: Sex
       • A: Age
       • D: Depression
       • P: Previous attempts
       • E: Excessive alcohol
       • R: Rational thinking loss
       • S: Separated, divorced, widowed
       • O: Organized attempt
       • N: No social support
       • S: Stated future intent
   • Depressed patients
     • Depression scale
     • PHQ-9
   • Psychotic patients (all patients with major psychiatric disorder must be asked about suicidality)
     • Schizophrenia Interview
   • Neurocognitive impairment
     • Mini-mental exam
     • Mini-cog exam
   • Alcoholism
     • CAGE questioning
     • Screening
   • Substance-abuse
     • CRAFFT questionnaire
   • Ask patients with history of frequent accidents about suicide

Treatment/Management

1. Basics
   • Refer immediately to psychiatry specialist
   • Direct questioning is not a very productive method at the beginning
     • Example: "Do you want to kill yourself?"
   • Use open-ended questions in order to elicit more information from the patient
   • When interviewing the patient start at the less serious end of the suicide spectrum
     • Determined the severity of the patient feelings
       • Hopelessness
       • Helplessness
       • Negativity
     • Assess suicidal ideation, plans or ideas to commit suicide
   • Once suicide ideas have been identified, proceed with more direct questioning about suicidal plans and/ or intents
     • Take all suicide threats seriously especially with a practical and lethal plan
     • Ask about the onset and frequency of ideations
     • Ask about methods of ideation
       • Evaluate the lethality and specificity of the ideation
       • Evaluate patients access to potentially harming weapons or tools of ideation
   • If a potentially self-destructive patient wants to leave office or ED prior to evaluation, he or she should be detained until the evaluation has been completed (document reasoning carefully)
   • Give more weight to history, risk factors and collateral information than patient's word
     • Often a truly suicidal patient will not admit it
     • Be conservative and hospitalize (involuntarily if necessary) if you have any doubt regarding patient's safety
   • After interviewing the patient, prioritize and organize risk factors
     • Chronic and/or predisposing factors
     • Acute and/or exacerbating factors
     • Presence or absence of protective factors (e.g., religious beliefs, motivations)
     • Determine imminent risk for suicide (e.g., clear plan and intention to implement it, psychosis)

Prevention

1. Screening
   • Insufficient evidence to recommend for/against routine screening by primary care clinicians to detect suicide risk in general population (Go to USPSTF)
     • Does not apply to pts w/ existing psychiatric disorders or past histories of suicide attempts
2. The following decrease suicide rates
   • Early identification and management
   • Physician education on recognition and treatment of depression
   • Referral to psychiatry
   • Limited access to lethal means
     • Firearms
     • Detoxification of domestic gas
     • Restrictions on prescription and sale of barbiturates
   • Providing community support
   • Establishing a systemic management plan ("Safety Plan")
     • Calling 911 when the patient is worried about hurting himself
     • Head to ER if suicide thoughts appear
     • Include family members and friends names and phone numbers to call
     • Enroll in self-soothing activities

Evidence-Based Inquiries

• What interventions are effective for the prevention of suicide?
• 5 Things to know about screening for suicide risk in primary care

Related Tests and Topics

• Alcohol
• Drug screen

References

1. Bickley, Lynn S. MD, FACP, Szilagyim Peter G., MD, MPH, (eds). Behavioral and Mental Status. Bate's Pocket Guide to Physical Examination and History Taking, 8th ed., Philadelphia, PA. Wolters Kluwer. 2017; Ch.5.
2. Greenberg J, Tesfazion AA, Robinson CS. Screening, diagnosis, and treatment of depression. Mil Med. 2012 Aug;177(8Suppl):60-6. Review.
3. O'Connor EA, Perdue LA, Coppola EL, et al. Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2023;329(23):2068-2085.
4. Ronguillo L, Minassian A, Vike GM, Wilson MP. Literature-based Recommendations for Suicide Assessment in the Emergency Department. J Emerg Med. 2012 October 2 pii: S0736-4679(12)01073-6.
5. Sewell DD, Koh S, Maglione J, Greytak R, Marrone L, Jeste DV. General Topics in Geriatric Psychiatry. In: Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Supiano MA, Ritchie C., (eds). Hazzard's Geriatric Medicine and Gerontology, 7th ed., New York, NY. McGraw-Hill. 2017; Ch. 73.
6. Schneider RK. The Suicidal Patient. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB., (eds). Principles and Practice of Hospital Medicine, 2nd ed., New York, NY. McGraw-Hill. 2017; Ch. 227.
7. US Preventive Services Task Force, Barry MJ, Nicholson WK, et al. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(23):2057-2067.
8. WHO- World Health Organization. Suicide. Available at: https://www.who.int/news-room/fact-sheets/detail/suicide [Accessed October 2023]
9. Suicide Risk. StatPearls [Internet]; May 29th, 2023. Available at: https://www.ncbi.nlm.nih.gov/books/NBK441982/ [Accessed October 2023]

Contributors

1. Pacheco, Caleb S., MD
2. Ausi, Michael, MD, MPH

Updated/Reviewed: October 2023