liveonearth (liveonearth) wrote,

Recognizing Suicidality

Recognizing Suicide Risk Factors in Primary and Psychiatric Care
by Larry Culpepper, MD, MPH

75% of suicides had contact with primary care doc during year before death
1/3 had contact with mental health services
2x more had primary care contact
than mental health svc contact in month before death (45% vs 20%)

major depression-->20x suicide risk
hx of major depression present in ~60% of suicides
~8% of depressed make attempts, more with comorbid anxiety disorders
(25% with panic disorder, 38% w/ ptsd

31,000/yr in US
1 million/yr worldwide
650,000 txed/yr in US for attempts

inquiry does not increase attempts
pts unlikely to verbalize w/o inquiry
seeking an office visit mb a sign of suicidality
most pts will tell if asked
no proof that screening for suicidality in primary care reduces suicides/attempts
depression screening/severity assessments incl Q's about suicide
(Patient Health Questionnaire (PHQ)-9 and Quick Inventory of Depressive Symptomatology (QIDS))
(have you thought that you would be better off dead or hurting yourself in some way?)

we do not have instruments that predict which patients w/ ideation will attempt
it's up to the physician to decide when/if to intervene

--past attempts (1/2 of suicides have tried before, 1/100 who have tried are successful within the next year, that's 100x greater risk than general pop)
--multiple psychiatric conditions higher risk than dep or anx alone
--depression, bipolar disorder, alcoholism or other substance abuse, schizophrenia, personality disorders, anxiety disorders (including panic disorder), PTSD, delirium
--anxiety disorders-->2x risk
--depression and anxiety-->17x risk
--intoxication: 20% to 25% of suicides are
--more attempts among youth, more success with age
--men 3x better at it than women, use more lethal methods
--women make 4x more attempts
--whites are 90% of suicides
--72% of all suicides are white men
--unemployed and unskilled, occupational failure
--physicians esp female physicians (2.3xmore for females, 1.4x more for males)
--hopelessness-->1.3x more imp than depression
--hopelessness persisting when depression has remitted-->still high risk
--substance abuse-related disinhibition
--combinations more risky than individual risk factors
--illness: chronic pain, chronic disease, recent surgery
--(HIV infection alone does NOT increase risk)
--1st degree relative suicide-->6x risk
--never married most risk, and in descending order: widowed, separated, divorced, married w/o children, married with children
-live alone
--lost a loved one
--failed relationship within one year
--anniversary of a significant loss
--spouse who committed suicide
--abuse and other adverse childhood experiences (incr risk in adults)
--access to means: firearms-->57% of all US suicides, 62% in men
--firearms in house-->4-10x more adolescence suicide
--#2 most popular methods: hanging for men, poisoning for women
--family discord

--family connectedness and social support
--parenthood (more for mothers)
--religious activities and religiosity

presence, frequency, and duration of suicidal thoughts
intensity and content
changes in chronic thoughts
whether or how the patient has been controlling these thoughts
poss start: ask whether the patients feels he or she would be better off dead
lost interest in living?
thought of ending his or her life?
expectations from death?
(motivations: reuniting with loved one, punishing others, escape painful situation)
what is the suicide plan? method, place, time?
preparations? (gather pills, change wills, write note)
practiced? prior attempt?
anticipated outcome?
means available? know how to use them?
lethality of the plan? conception of lethality vs objective lethality?
likelihood of rescue?
strength of the intent?
ability to control impulsivity?
ID precipitating events: death of loved one; breakup; work, school, social failure; sexual identity crisis; trauma
sense of hopelessness?
alcohol and substance abuse? binging, impulsivity, family/soc supports/stressors
is pt engaged in and complying with treatment?
recent stressors?

estimate risk for suicide and manage accordingly

suicide might be attempted within the next 48 hours
active plan or intent to harm themselves
lethal means readily accessible
psychotic (esp hearing voices telling them to commit suicide)
cognitively impaired
lack judgment
-->immediate hospitalization via ambulance
electroconvulsive therapy may be lifesaving

but not imminent
ex: with a desire to commit suicide but no specific plan
aggressive treatment, not hospitalization
interventions: psychiatric treatment; control of substance use; mobilizing family/social supports; reducing access to firearms, medications, or other potentially lethal means; and ensuring frequent contact with helping professionals and supports
address contributing factors: precipitating events, ongoing life difficulties, and comorbid mental disorders
contract for safety
strong therapeutic alliance
direct communication
frequent re-evaluation are recommended
supportive primary care counseling
referral for psychotherapy
engagement of community, religious, and family supports can be helpful
cognitive-behavioral therapy if hopeless

antidepressants now have suicide as possible adverse effect on label
doc must educate and frequently re-evaluate patients w depression/suicidality
'98-'03: 91% incr in US antidepressant prescriptions
and 33% decline in completed suicide
this was before the addition of the warnings about suicide risk with SSRI
sim in Netherlands had similar experience
warnings issued by FDA and in Eur in 2003
-->22% decrease in SSRI scripts for youths in US and Nederlands
-->14% incr in suicide in US in 2003-4, 49% incr in The Netherlands 2003-2005
-->so don't avoid SSRIs dt fear of suicide, but monitor carefully

(where you can find all the references)

also another medscape article with cases that you can test yourself with:
Tags: anxiety, death, depression, ptsd, suicide

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