Suicide is one of the most tragic outcomes in clinical practice. It is not predictable in the individual and results from a complex series of factors that may differ across individuals, yet 30 – 70% of suicides occur in patients who are receiving some treatment of psychiatric disorder.
Suicide has been defined as a “fatal self-inflicted destructive act with explicit or inferred intent to die” (Instititue of Medicine of the National Academies, 2002).
- A suicide attempt is an intentional action taken to kill oneself that does not result in death.
- Individuals with suicidal ideation wish to kill themselves but have taken no action toward suicide. Suicidal ideation may vary in seriousness, as reflected in the details of the suicidal plan and the degree of suicidal intent.
- Suicidal intent is the intensity of the wish to die. Suicidal thoughts can be present without intent, in which case the thoughts are referred to as passive suicidal ideation.
- The lethality of suicidal behavior is the objective danger to life associated with a suicide method or action. Lethality is distinct from and may not always coincide with an individual’s expectation of what is medically dangerous.
- Deliberate self-harm is the willful self-infliction of painful, destructive, or injurious acts without the intent to die. Many patients who engage in self-harm not intended to their life state that they feel a sense of “relief”; for example, a patient who was quite angry at a friend felt much better after cutting herself with a razor.
Patient with suicidal thoughts or behavior commonly feel frustrated, helpless, or hopelessOpens in new window. They tend to become extremely pessimistic when their repeated attempts to solve problems appear to have failed. They may verbalize that they feel like a burden to others.
Suicidal individuals often have a style of thinking that can be described as “tunnel vision,” leading them to believe suicide is the only solution to their problems. They are frequently angry, self-punishing, and harshly self-critical.
They may describe themselves as stupid or worthless and say they deserve to die. Some covertly use their symptoms or threats of suicide to control other persons, saying, in effect, “Do what I want or I will kill myself.”
|Table X-1 Epidemiology of Suicide|
Self-destructive or violent ideation varies in its degree of risk.
- Deliberate planning of a destructive act for which the patient has the means suggests a high risk.
- Psychotic patientsOpens in new window who are suicidal in response to delusions or to command auditory hallucinationsOpens in new window are at high risk.
- Similarly, patients suffering from command auditory hallucinations or delusions involving killing or hurting someone else are high risk (e.g., a patient who has delusionsOpens in new window that “I am doing God’s work by killing”).
Patients who view suicide as a solution to a specific problem are at high risk. For example, a man wanted to kill himself to get away from a job that was particularly stressful after he was unable to find other work for some time.
Patients who have not made a plan and are ambivalent about hurting themselves have a lesser risk. Patients with ambivalent or fleeting thoughts or fantasies are low risk, particularly if they have no intention of action. For example, a person who makes a superficial cut on her wrist and then calls a family member appears ambivalent about commiting suicide.
Persons with violent impulses are most likely to commit a dangerous act in the near future if they have an intense desire to kill a specific person (e.g., a drug dealer who wants money that he feels another drug dealer owes him). Patients with a nonspecific wish to hurt or kill someone are at lower risk (e.g., a patient who wants to kill all police officers).
A history of past suicide attempts is a risk factor for future suicide. Risk may be increased by more serious, more frequent, or more recent attempts.
The physician should inquire about past suicide attempts and self-destructive behaviors, including specific questioning about aborted suicide attempts. Examples of the latter would include putting a gun to one’s head but not firing it, driving to a bridge but not jumping, or creating a noose but not using it.
The physician should also explore details about the precipants, timing, intent, and consequences as well as the medical severity of the attempt.
The patient’s consumption of alcohol and drugs before the attempt should also be ascertained, since intoxication can facilitate impulsive suicide attempts but can also be a component of a more serious suicidal plan. The physician should question the patient about the outcome of each attempt. Last, the physician must ask about the patient’s reaction to surviving the suicide attempt. If the patient has had many attempts, explore in detail the “worst” suicidal episode, as well as the first and last attempts.
Most patients with suicidal symptoms have at least one psychiatric diagnosis. Mood disordersOpens in new window are particularly associated with an increased risk of suicide during a depressive episode. Patients with depression are more likely to commit suicide if they have panic attacksOpens in new window, insomnia, or alcohol or drug abuse. Those who are recovering from depression and who gain energy may be at increased risk as well.
Compared to the general population, those with schizophrenia are about 8.5-fold more likely to commit suicide, with a lifetime risk of about 4%. Suicide may occur more frequently during the early years of this illness, and the time immediately after hospital discharge is a period of heightened risk. Although psychotic symptoms are often present at the time of an attempted or completed suicide, suicide may occur during periods when psychotic symptoms are improving.
Sometimes suicide occurs in patients with schizophrenia when additional depressive symptoms are present. Suicide risk may paradoxically be increased in those who have insight into the implications of having a psychotic illness, particularly if this insight is coupled with a feeling of hopelessness.
AlcoholismOpens in new window and drug abuse are associated with an increased risk for suicide, approximately six times that of the general population. Recent or impending interpersonal losses and comorbid psychiatric disorders have been linked to suicide in alcoholic individuals. Suicide is also more likely to occur among alcoholics who suffer from depressive episodes than in persons with major depression or alcoholism alone.
Compared to the general population, individuals with personality disorders have an estimated risk for suicide that is about seven times greater. Specific increases in suicide risk have been associated with borderline and antisocial personality disorders. Personality disorders have been identified in approximately 30% of those who commit suicide.
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- Shneidman E. S.Autopsy of a Suicidal Mind. New York: Oxford University Press, 2004.
- Rudd M. The Assessment and Management of Suicidality. Sarasota, FL: Professional Resource Press, 2006.
- Maris R., A. Berman, and M. Silverman. Comprehensive Textbook of Suicidology. New York: Guilford, 2000.
- Posner K., M.A. Oquendo, M. Gould, B. Stanley, and M. Davies. Columbia classification algorithm of suicide assessment (C-CASA): classification of suicidal events in the FDA’s pediatric suicidal risk analysis of antidepressants. American Journal of Psychiatry 164: 1035 – 1043, 2007.