| Variable | Risk Factors |
|---|---|
| Demographic | Male gender, Caucasian race, rural residence, possibly age (varies among studies) |
| Imprisoned; widowed, divorced, or separated; living alone; no children or no children living in the home | |
| Psychosocial | Lack or loss of social supports, recent loss of employment, decrease in socioeconomic status or poverty, hopelessness |
| History of victimization (physical or sexual abuse), psychological turmoil, severe relationship conflict, aggressive or impulsive traits | |
| Writing suicide notes; family history of suicide, previous attempts, ‘imitation’ suicide, gun ownership | |
| Occupational risk (physicians, dentists, nurses, pharmacists, veterinarians, farmers) | |
| Psychiatric | Psychiatric diagnosis of recent onset |
| Mood disorder, particularly major depression and bipolar disorder | |
| Schizophrenia; alcohol or other substance abuse or addiction; personality disorder; panic attacks or severe psychic anxiety | |
| Insomnia; poor concentration or confusion; anhedonia | |
| Medical | Huntington’s disease, stroke, multiple sclerosis, head injury, spinal cord injury, systemic lupus erythematosus, AIDS |
| Epilepsy, pain, malignant neoplasms, peptic ulcer disease, renal disease | |
| Source: Adapted with permission from reference 3 | |
Table 2
Potentially protective factors against suicide
| Internal |
| Successful past responses to stress |
| Positive coping skills |
| Spirituality |
| Capacity for reality testing |
| Frustration tolerance/optimism |
| Overall individual resiliency |
| External |
| Children or pets in the home |
| Religious prohibition or beliefs |
| Positive therapeutic relationships |
| Sense of responsibility to family |
| Social supports and connections |
| Financial incentives or deterrents |
| Source: Adapted from reference 11 |
Table 3
Evaluating suicide risk: Questions to ask patients
| Have you felt so sad or depressed that you thought life is not worth living? |
| Have you thought about hurting yourself or taking your own life? |
| Have you thought about a way or plan to kill yourself? |
| Do you have the means to complete the plan? (such as, do you have access to weapons or pills?) |
| Have you practiced or rehearsed this plan to end your own life? |
| Do you have a location picked out? |
| What has stopped you from following through with the plan? |
| Have you ever attempted suicide? |
| Has anyone in your family ever attempted or committed suicide? |
| Source: Adapted with permission from reference 3 |
Interventions for suicidal patients
Physical protection. Take decisive action when you determine that suicide risk is elevated and imminent. Pursue urgent psychiatric hospitalization, with or without patient consent, in accordance with local probate and involuntary commitment statutes.
The logistics of protective action can be challenging; transportation is often required, and the patient is not always cooperative with admission. Table 4 lists measures and precautions that can help keep the suicidal patient safe.
Disease-specific interventions. Because suicidal ideation is often symptomatic of a primary psychiatric disorder, rapidly identifying major depression, bipolar disorder, or a psychotic illness is crucial to reducing suicidal thoughts and behaviors. Prescribe appropriate antidepressants, mood stabilizers, and antipsychotics at adequate doses and for sufficient duration.
Be vigilant for distressing symptoms that may be elevating the patient’s suicide risk, such as anxiety, panic, agitation, insomnia, or pain. Pharmacotherapies—such as anxiolytics, sedative-hypnotics, antipsychotics, or analgesics—may rapidly reduce suffering.
Impulsivity associated with substance use disorders—particularly during intoxication and withdrawal syndromes—requires aggressive attempts by the treatment team to engage the patient in detoxification and rehabilitation.
Direct antisuicide therapy. Clozapine carries an FDA-approved indication for preventing suicide in patients with schizophrenia or schizoaffective disorder. The mechanism by which clozapine helps prevent suicide is not known, but its anti-suicidal effects appear to be independent of its antipsychotic effects.12
Lithium has been reported to reduce risk of suicide and suicide attempts in patients with bipolar disorder, perhaps by as much as 80%.13 Such benefit has not been observed with other mood stabilizers, suggesting that lithium confers protective effects against suicide beyond its mood-stabilizing effects. Suicide risk is known to increase after lithium is discontinued.14
Lithium’s antisuicidal effects may arise from its ability to enhance serotonin. This theory, although unproven, is consistent with observations associating central serotonergic deficiency with suicidal and aggressive behaviors.
Psychosocial measures. Address psychosocial variables that may increase suicide risk (Table 1). Recruit and involve the patient’s support system, augmented with a close follow-up plan. Case management to explore housing and job opportunities can help. Work with the patient’s family or others to remove guns from the patient’s access. Individual, marital, and family therapies can reduce conflicts and strengthen coping skills.
Table 4
Safety measures to protect the suicidal patient
| Hospitalize—voluntarily or involuntarily—on a locked psychiatric unit |
| Provide constant 1-to-1 observation by staff |
| Transport the patient, accompanied by adequate personnel |
| Use physical restraints or seclusion while maintaining continuous observation |
| Employ metal detector to remove dangerous, hidden objects |
| Remove and secure patient’s belongings (bags, coats, purses may contain pills or weapons) |
| Search visitors’ belongings before allowing access to unit |
| Ensure that inpatient unit meets all coded safety regulations |
Related resources
- National Suicide Prevention Lifeline, sponsored by the Substance Abuse & Mental Health Services Administration: 1-800-SUICIDE or 1-800-273-TALK (8255); www.suicidepreventionlifeline.org.
- American Foundation for Suicide Prevention (AFSP) 1-888-333-AFSP; www.afsp.org.
- Simon RI, Hales RE. Textbook of suicide assessment and management. Washington, DC: American Psychiatric Publishing; 2006.