> Table of Contents > Suicide
Irene C. Coletsos, MD
Harold J. Bursztajn, MD
image BASICS
Suicide and attempted suicide are significant causes of morbidity and mortality.
  • Predominant sex
    • Women attempt suicide 1.5 times more often than men. Men complete suicide 4 times more often than women. Men are more likely to choose a means with high lethality.
  • Predominant age: adolescent (2nd leading cause of death, 10th leading cause of death overall, per 2013 CDC statistics [latest available]);
  • Predominant race: 84% of people who complete suicides are white, non-Hispanic. Native Americans have the next highest rate in the United States. Whites have twice the risk of suicide compared with African Americans.
  • Marital status: single > divorced; widowed > married
  • Worldwide, in of all countries, youths (ages 10 to 24 years) are the highest risk group.
  • In 2013, 10th leading cause of death in adults in the United States. Military service (not specifically active duty) is associated with increased risk. In 2009, 2010, 2012, and 2013, more soldiers died of suicide than in active duty, according to a congressional study and the National Center for Veterans.
  • Worldwide, the 3rd leading cause of death.
  • “Human understanding is the most effective weapon against suicide. The greatest need is to deepen the awareness and sensitivity of people to their fellow man” (Shneidman, American Association of Suicidology).
  • Be alert to a combination of “perturbation” (increased emotional disturbance) and “lethality” (having the potential tools to cause death).
  • 80% who complete suicides had a previous attempt.
  • 90% who complete suicide meet Diagnostic and Statistical Manual criteria for Axis I or II disorders: major depression, bipolar disorder, anorexia nervosa, panic disorder, borderline, and antisocial personality disorders. Schizophrenia or acute onset of psychosis are also risk factors, due to command hallucinations or even the negative affect or hopelessness that can accompany these states.
  • Substance use (alcohol, hallucinogens, opioids)
  • Family history of suicide
  • Physical illness
  • Despair: feeling unendurable emotional pain and has “given up” on self, feels without hope and, consciously or unconsciously, unworthy of help
  • Among teenagers: not feeling “connected” to their peers or family; being bullied; poor grades
  • Psychosocial: recent loss: What may seem to be a small loss (to a medical provider) may be a devastating loss to the patient. Patient-specific factors need to be taken into account: social isolation, anniversaries, and holidays. Patients who attempt suicide also seem to have impaired decision-making skills and risk awareness, and increased impulsivity, compared with patients who have never attempted suicide (1).
  • If a patient is incompetent (e.g., too delusional) to inform providers about the potential for suicide, that puts the patient at increased risk, consider hospitalization.
  • Access to lethal means: firearms, poisons (including prescription and nonprescription drugs)
  • Know how to access resources 24/7 within and outside of the health care institution.
  • Screen for risk factors, and consider the overall clinical picture. Screening instruments include the Patient Health Questionnaire-2 (PHQ-2), the PHQ-9, the Columbia Suicide Severity Rating Scale, Beck's Scale for Suicidal Ideation, Linehan's Reasons for Living Inventory, and Risk Estimator for Suicide.
  • Treat underlying mental illness and substance abuse. Screen for possession of means of harm, including prescription and nonprescription drugs and firearms (encourage these patients to remove guns from their homes and to relinquish gun licenses).
  • Women being treated for cancer, chronic obstructive pulmonary disease (COPD), heart disease, osteoporosis, or stroke were found to be at higher risk for suicide (even without a history of depression).
  • Create a safety plan for patients at risk for suicide and their families, including education about how to access emergency care 24 hours a day.
  • Public education about how to help others access emergency psychiatric care. Suicidal people may first confide in those they trust outside health care (e.g., family members, religious leaders, community elders, “healers,” hairdressers, and bartenders).
  • For the military: multiple resources: www.realwarriors.net. Suggested treatments include cognitive restructuring techniques (that their experience with adversity can be a sources of strength) and help with problem-solving (so the service member does not feel like a “burden”) therapeutic martial arts training; focus on Vets' helping others: “Power of 1” initiative (any “one” helpful contact could save a life).
  • For teens, young adults, and their educators: suggestions and advice for students/families and educators: www.cdc.gov/healthyyouth/adolescenthealth; http://www.stopbullying.gov
  • In developing world countries, pesticide ingestion is a common method of suicide. Limiting free access has led to reduced suicide rates.
  • Medical conditions: delirium, intoxication, withdrawal, medication side effects
  • Psychosis: Observe for signs of/ask about command auditory hallucinations to kill oneself, delusional guilt, and persecutory delusions.
  • In adults: Observe for signs of hopelessness/despair (see “Risk Factors”).
  • In teens: Screen for risk factors: substance abuse, bullying and social isolation (both common via electronic media), poor grades, because teens may not appear depressed.
Differentiate between patients and pseudopatients (i.e., those who are using suicide threats and gestures to manipulate others).
Diagnostic Procedures/Other
Brief tests that could be part of any medical/mental health assessment:
  • PHQ-9: http://www.med.umich.edu/1info/FHP/practiceguides/depress/phq-9.pdf
  • Columbia Suicide Severity Rating Scale, clinical instructions accessed at: http://www.cssrs.columbia.edu/scales_practice_cssrs.html
  • Suicide Trigger Scale version 3 (STS-3), which measures a patient's “ruminative flooding” (self-critical, repetitive thoughts) and “frantic hopelessness” (feeling trapped, suicide is the only choice): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3443232/
  • Patients expressing active suicidal thoughts or who made an attempt require immediate evaluation for risk factors, mental status, and capacity (to determine if they are able/or willing to inform treaters about suicidal intentions), as well as a formal psychiatric consultation. Careful primary care screening can be as effective at identifying risk as a psychological assessment.
  • Cognitive therapy decreased reattempt rate in prior suicide attempters by half. (i) Establish therapeutic alliance. Have patient tell a story about recent suicidal thought or action. (ii) Help patient develop the skills needed to deal with the thoughts or feelings that trigger suicidal crises. (iii) Have patient imagine being in the situation that brought on the earlier crisis, but this time, guide that patient to practice problem-solving strategies—reinforcing the use of coping skills, rather than suicidal actions (2)[B],(3).
  • Psychotherapy with suicidal patients is a challenge even for the most experienced clinicians. The countertransference, a clinician's feelings toward

    a patient, can evolve into wanting to be rid of the patient. If the patient detects this, the risk of suicide is heightened. The clinician can avoid this by recognizing countertransference and bearing it within so that the patient remains unaware (4).
  • Among military personnel: ACE campaign: Ask about suicidal thoughts; care for the person, including removing access to lethal weapons; “escort” the soldier for help: an emergency room, to calling 911, or a support hotline such as (800) 273-TALK (8255); text: 838255
  • Psychopharmacology “is not a substitute for getting to know the patient” (5)[A].
  • Patients are at increased risk of suicide at the outset of antidepressant treatment and when it is discontinued. Consider tapering/switching medical therapies rather than sudden discontinuation. Monitor carefully at these times.
  • Anxiety, agitation, and delusions increasing in intensity are risk factors for suicide and should be treated aggressively.
  • In patients with mood disorders, a meta-analysis of randomized, controlled trials found that lithium reduced the risk of death by suicide by 60% (5)[A].
  • Agitated or combative patients may require sedation with IV or IM benzodiazepines and/or antipsychotics. Clinical response is typically seen within 20 to 30 minutes if given IM/IV.
Pediatric Considerations
FDA posted black box warning for antidepressant use in the pediatric population after increased suicidality was noted. If risk of untreated depression is sufficient to warrant treatment with antidepressants, children must be monitored closely for suicidality.
First Line
ECGs before prescribing or continuing antidepressants or antipsychotics to look for QT prolongation
Consider a psychiatric consult. All decisions regarding treatment must be carefully documented and communicated to all involved health care providers.
Admission Criteria/Initial Stabilization
  • Inpatient hospitalization, if patient is suicidal with a plan to act or is otherwise at high risk; if immediate risk for self-harm, may be hospitalized involuntarily
  • Immediately after a suicide attempt, treat the medical problems resulting from the self-harm before attempting to initiate psychiatric care.
  • Order lab work (e.g., solvent screen, blood and urine toxicology screen, aspirin and acetaminophen levels). Patients may not disclose ingestions if they wish to succeed in their attempt or if they are undergoing mental status changes.
  • Risk for self-harm continues even in hospital setting. Immediate search for and remove potentially dangerous objects, one-to-one constant observation, medication. Mechanical restraints only if necessary for patient safety
  • The period after transfer from involuntary to voluntary hospitalization is also a time of high risk.
Discharge Criteria
  • No longer considered a danger to self/others
  • Clinicians should be aware that a patient may claim that he or she is no longer suicidal in order to facilitate discharge—and complete the act. Look for clinical and behavioral signs that the patient truly is no longer in despair and is hopeful, such as improved appetite, sleep, engagement with staff, and group therapy. Clinicians should check with family and ancillary staff because patients may share more information with them than with doctors.
  • Provide information about 24/7 resources.
Patient Monitoring
  • Increase monitoring at the beginning of treatment, when changing medications, and on discharge.
  • Educate family members and other close contacts/confidants to the warning signs of suicidality. For adults: despair/hopelessness, isolation, discussing suicide, stating that the world would be a “better place” without them, losses in areas key to the patient's self-worth. For youths: may exhibit the same signs and symptoms, but one should be aware of these additional risks: history of abuse (e.g., sexual, physical), bullying in person or via electronic media (e.g., text messages or social Web sites), family stress, changes in eating and sleeping patterns, suicidality of friends, and giving away treasured items
  • Make sure that the patient is willing to accept the type of follow-up offered. Do not assume that just setting it up is sufficient protection.
  • Curtail access to firearms.
  • Limiting the number of pills may be appropriate for an impulsive patient. However, clinicians may believe that by simply limiting the number of pills they prescribe, they are preventing further suicide attempts, an example of “magical thinking.” Clinicians who find themselves thinking this way can take it as a warning sign that their patients may actually be at increased risk of suicide.
Patients who feel they are in danger of hurting themselves should consider one or several of these options:
  • Call 911.
  • Go directly to an emergency room.
  • If already in counseling, contact that therapist immediately.
  • Call the National Suicide Prevention Hotline at (800) 273-TALK (8255).
  • Servicemen and servicewomen and their families can call (800) 796-9699; if there is no immediate answer, call (800) 273-TALK (8255); text 838255.
The key to a favorable course and prognosis is early recognition of risk factors, early diagnosis and treatment of a psychiatric disorder, and appropriate intervention and follow-up.
1. Jollant F, Bellivier F, Leboyer M, et al. Impaired decision making in suicide attempters. Am J Psychiatry. 2005;162(2):304-310.
2. Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5):563-570.
3. Ghahramanlou-Holloway M, Neely L, Tucker J. A cognitive behavioral strategy for preventing suicide. Current Psychiatry. 2014;13(8):19-28.
4. Maltsberger JT, Buie DH. Countertransference hate in the treatment of suicidal patients. Arch Gen Psychiatry. 1974;30(5):625-633.
5. Cipriani A, Pretty H, Hawton K, et al. Lithium in the prevention of suicidal behavior and all-cause mortality in patients with mood disorders: a systematic review of randomized trials. Am J Psychiatry. 2005;162(10):1805-1819.
6. Massicotte WJ. Faculty, Canadian Institute of Psychoanalysis; Chair, National Scientific Program Committee. Correspondence, April 24, 2009.
Additional Reading
  • Bryan CJ, Jennings KW, Jobes DA, et al. Understanding and preventing military suicide. Arch Suicide Res. 2012;16(2):95-110.
  • O'Connor E, Gaynes BN, Burda BU, et al. Screening for and treatment of suicide risk relevant to primary care: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;158(10):741-754.
  • R45.851 Suicidal ideations
  • T14.91 Suicide attempt
  • Z91.5 Personal history of self-harm
Clinical Pearls
  • Key preventative measure is to listen to a patient and take steps to keep him or her safe. This could include immediate hospitalization. Questions to explore include, “Are you thinking of killing yourself?,” “Who do you have to live for?,” and “What should change so that you could live with your suffering?”
  • Clozapine, lithium, and cognitive-behavioral therapy are associated with a reduction in the risk of suicide.
  • Family members and contacts of people who have attempted or committed suicide suffer from reactions ranging from rage to despair. Their grief is often longer lasting and less well-treated because of the shame and guilt associated with the act. Encourage them to discuss this and consider counseling.
  • Resources for clinicians: www.suicidology.com; www.suicideassessment.com