MENTAL HEALTH CLINICIANS
This section contains material for mental health clinicians pertaining to the assessment and treatment of patients who may be suicidal or are suicidal, including special at-risk populations. The information is based on a review of available evidence and clinical consensus. For a complete list of references, click here.
STATEMENT OF INTENT: STRENGTHS AND LIMITATIONS
The information in this section is not to be construed or to serve as the standard of care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to clinical change as scientific knowledge and technology advance and practice patterns evolve. Areas that refer to practice should be considered informational only. Adherence to the information presented in this section will not ensure a successful outcome for every individual. Moreover, this section does not include all proper methods of assessment/treatment and may exclude other acceptable methods aimed at the same results. The ultimate judgment regarding a particular clinical procedure, treatment plan, or suicide assessment must be made by the health care provider in light of clinical data presented by the patient and the diagnostic and treatment options available at the time of evaluation.
(Adapted from APA, 2003)
Uniform Suicide Terminology
The following definitions are adapted from the U.S. Center for Disease Control and Prevention (CDC), Division of Violence Prevention (Crosby et al., 2011) and the American Psychiatric Association’s Practice Guidelines for the Psychiatric Evaluation of Adults (APA, 2016). They define common terms regarding suicide.
Aborted or self-interrupted attempt: When a person begins to make steps towards making a suicide attempt but stops before the actual act or behavior.
Affected by Suicide: All those who feel the impact of suicidal behaviors, including those bereaved by suicide, friends, community, or celebrities.
Bereaved by Suicide: Family members, friends, co-workers, others affected by the suicide of a loved one. Can be referred to as survivors of suicide loss.
Interrupted Attempt: When a person is interrupted by another person or outside circumstances from carrying out a self-destructive act after making preparations and/or taking steps in furtherance of the attempt.
Means/Methods: The instrument, material, or method used to engage in self-inflicted injurious behavior, presumed to be suicidal if there is evidence of any intent to die as a result of the behavior.
Non-Suicidal Self Injury (NSSI): The intentional injury of one’s own body tissue without suicidal intent and for purposes not socially sanctioned, such as carving, cutting, or burning yourself, banging or punching objects or yourself, and embedding objects under your skin. Tattooing and piercing are not considered NSSI because they are considered to be culturally sanctioned forms of expression.
Protective Factors: Factors that make it less likely that an individual will engage in suicidal behavior.
Risk Factors: Factors that make it more likely an individual will engage in suicidal behaviors.
Safety Plan: A collaborative plan between patient and clinician that contains a written or verbal list of warning signs, coping responses, supports (both lay and professional), and emergency contacts that an individual may use to avert thoughts, feelings or impulses or behaviors related to suicide, including restriction of access to lethal means.
Suicidal Behaviors or Preparatory Actions: Acts or preparation toward making a suicide attempt that includes any evidence of intent to die.
Suicidal Ideation: Thoughts of engaging in suicidal behaviors or serving as the agent of one’s own death (active ideation), or preoccupation with death or being dead (passive ideation).
Suicidal Intent: Expectation and desire for a self-injurious act to end in death. Evidence that at the time of injury the individual intended to kill self and understood the consequences of relevant actions.
Suicidal Plan: Delineation of the method, means, time, place, or other details for engaging in self-inflicted injurious behavior with any intent to die as a result of the behavior.
Suicidal Thoughts: General nonspecific thoughts of wanting to end one’s life (either active or passive).
Suicide: Death caused by intentional self-directed injurious behavior with any intent to die. Instead of “committed” or “completed,” it is currently recommended to use the phrase, “died by suicide.”
Suicide Attempt: A non-fatal, self-directed, potentially injurious behavior with any intent to die as a result of the behavior with or without injuries.
The purpose of suicide risk assessment is to identify factors that may increase or decrease suicide risk, address immediate safety needs, determine the treatment setting, and develop a differential diagnosis to help guide treatment. The extensiveness of suicide assessments varies, depending on the patient’s clinical presentation, the patient’s capacity or willingness to provide information, the patient’s mental state, the clinician’s previous experience with the patient, the clinical setting, and other such factors. The goal of identifying risk and protective factors in a suicide assessment is not prediction, but rather to determine the next steps and to plan more informed interventions (APA, 2016).
Clinical situations that may warrant a suicide risk assessment
- Emergency department or crisis evaluations
- Intake evaluations
- Persons with depression anticipating or experiencing significant loss or stress (relationship difficulties, financial loss, humiliation, legal difficulties)
- Persons with certain physical illnesses (particularly if life threatening, disfiguring, or associated with severe pain or loss of function)
- Pertinent clinical change (increase in suicide ideation, suicidal behavior, change in mental status, unstable mood, impulsiveness, experience of loss, trauma victimization)
The Issue of Prediction
In 2019, the suicide rate in the United States was 14.2 per 100,000 people (CDC, 2020). Even though there has been a recent increase in the suicide rate, it is still a rare event even among high risk populations. This statistical rarity of suicide contributes to the impossibility of predicting suicide for an individual based on the presence of risk factors, alone or in combination. A recent comprehensive review found that the ability to predict if someone will attempt to take his or her own life is no better than chance and has not significantly improved over the past 50 years (APA, 2016; Franklin et al., 2017). The goal of identifying risk and protective factors in a suicide assessment is not prediction, but rather to determine the level of suicide risk (low, medium, or high) and to plan more informed interventions. For example, some risk factors are potentially modifiable, such as treating psychiatric disorders and symptoms, involving social supports (when available), and reducing access to lethal means.
Demographic and Other Static Risk Factors
- U.S. males are 3 to 4 times more likely than females to die by suicide, but females are more likely to make suicide attempts than males (Hedegaard et al., 2020; APA, 2017).
- Single, widowed, or divorced people are twice as likely to complete suicide as married people (Curtin & Tejada-Vera, 2019).
- Suicide attempts are 4 times more common among those who identify as lesbian, gay, or bisexual than those who identify as heterosexual (Youth Risk Behavior Survey, 2017).
- The U.S. suicide rate is highest among American Indian/Alaskan Native populations (SAMHSA, 2010; SPRC, 2020).
- While the overall suicide rate of those identifying as black is lower than that for other racial/ethnic groups, suicide attempts among black adolescents have increased significantly over the past few decades (Lindsey et al., 2019).
- Certain occupational groups, such as construction workers and health care professionals (including physicians, dentists, and veterinarians), have relatively high rates of suicide (Hawton et al., 2011; Tomasi et al., 2019).
- However, being unemployed, under financial strain, or homeless is also associated with substantially higher risk of suicide (SPRC, 2012).
Suicidal and Non-Suicidal Self-Injury
Past suicide attempts: Most people who make an unsuccessful suicide attempt do not ultimately die by suicide (Bostwick et al., 2016). However, prior suicide attempts are both a short- and long-term risk factor for suicide, and, thus, must be followed up and taken seriously. Factors to consider are the intent and lethality of the attempt, as well as risk factors such as gender and age. Studies have found an increased risk of suicide within the first year following an attempt (Isometsa, 1998) as well as one year after the attempt (Fawcett, 1990). Aborted/interrupted attempts are also important to consider and should be assessed clinically as actual suicide attempts.
Non-suicidal self injury (NSSI): Non-suicidal self-injury (NSSI) is the “intentional destruction of one’s own body tissue without suicidal intent and for purposes not socially sanctioned” (Klonsky et al., 2014). NSSI includes behaviors, such as carving, cutting, or burning yourself, banging or punching objects or yourself, and embedding objects under your skin. Tattooing and piercing are not considered NSSI because they are considered to be culturally sanctioned forms of expression (Klonsky et al., 2014).
Approximately 15% to 20% of adolescents and young adults engage in self-injury at least once. NSSI is far less common in adults, with about 6% of adults reporting self-injury. NSSI presents differently in males and females. Females are more likely to engage in cutting, whereas males are more likely to self-injure by hitting or burning. Nevertheless, NSSI is still a risk factor for suicide, and should be seriously considered when assessing suicide risk, regardless of the person’s age or the degree of destruction (Klonsky, 2011; Klonsky et al., 2014).
Genetics and Neurobiology
Family History: Those who have first-degree relatives who died by suicide are at significantly increased risk of suicide compared to those who do not have relatives who died by suicide (Egeland & Sussex, 1985; Qin et al., 2002; Rostila et al., 2013). Twin studies indicate a higher concordance of suicidal behavior between identical twins than between fraternal twins (Egeland & Sussex, 1985; Roy et al., 1991; APA, 2003). Adoption studies show a greater risk of suicide among biologic relatives than among adoptive relatives (Brent & Melhem, 2008).
It is important to emphasize that suicide itself is inheritable, independent of any psychiatric disorder (Brent & Melhem, 2008; Offord, 2020). However, the link between family history and suicide is not solely genetic. Environment also plays a role, as having an unrelated spouse who commits suicide has also been shown to increase suicide risk (Agerbo, 2003; APA, 2003). Psychologically, the phenomenon of suicide in a family communicates to family members that suicide is permissible or a solution to a problem.
Having a family history of abuse, violence, or other self-destructive behaviors also places individuals at increased risk for suicide. Histories of childhood physical abuse and sexual abuse, as well as parental neglect and separations, have been associated with suicide and a variety of self-destructive behaviors in adulthood (Lopez-Castroman et al., 2014).
Neurobiology: Specific neurotransmitter systems have been linked to suicidal behaviors. For example, studies have found reduced serotonin or serotonin turnover, disruptions in serotonergic signaling, and lower levels of the serotonin transporter SERT in brain regions of suicide decedents. The reduction in serotonergic activity occurs regardless of psychiatric diagnosis or method of suicide. Lower CSF 5-HIAA levels, the main metabolite of serotonin, have been associated with suicide and suicide attempts, as has increased 5-HT2 receptor density in the amygdala. There is also evidence that reduced noradrenergic function can be associated with suicide (Mann & Arango, 1999; Offord, 2020).
Studies also suggest that the hypothalamic-pituitary-adrenal (HPA) axis, the pathway that controls the body’s response to stress, may be linked to suicide. Postmortem brain samples show that those who died by suicide have higher levels of corticotropin-releasing hormone (CRH), which causes the release of the stress hormone cortisol and other glucocorticoids. They are also more likely to have enlarged adrenal glands, which produce cortisol (Offord, 2020). Research using the dexamethasone suppression test (DST) indicates that higher levels of cortisol may be correlated with suicidality (Coryell and Schlesser, 2001). However, the studies did not control for mood disorders, so it is not known whether these differences are specific to suicide or not (Offord, 2020).
Researchers are increasingly viewing suicide risk using a stress-diathesis model. These models propose that suicide results from an interaction between predispositional factors (e.g., family history, genetics) and precipitating risk factors (e.g., stressful life events, psychosocial crises, psychiatric disorders). The question is why certain individuals with depression and other psychiatric disorders become suicidal, while others do not. Cognitive and personality traits, such as impulsivity, aggression, hopelessness, pessimism, and increased sensitivity to disapproval, likely play a role (Heeringen, 2012; Mann et al., 1999). There is also evidence that both serotonin signaling and HPA axis function can be affected by childhood adversity via epigenetic changes (Offord, 2020).
Modifiable Risk Factors
Psychiatric: Some studies have found that 90%-95% of persons who die by suicide have a psychiatric illness (Schreiber & Culpepper, 2019), though there has been some recent questioning of the universality of these findings. The CDC found that a mental disorder diagnosis was not known in 54% of all suicide cases in 2015, thus highlighting the need to pay careful attention to those who are experiencing intolerable mental or psychic pain, whether or not they meet full criteria for a psychiatric diagnosis (Pompili, 2020).
|Mental Health Conditions
Associated with Suicide
The psychiatric disorders most commonly associated with suicide are severe depression, bipolar disorder, substance abuse/alcohol use disorder, and schizophrenia (Edwards et al., 2020; Nordentoft et al., 2011; Tidemalm et al., 2008). The severity of the psychiatric illness can increase risk, as can comorbidity (e.g., depression with an anxiety disorder, psychotic symptoms, personality disorder, and abuse of alcohol or other substances).
Studies have found that patients who have recently been discharged from an inpatient psychiatric facility are at increased risk for both suicide attempts and suicides. A recent comprehensive review found that 26.4% of suicidal acts occur within the first month after discharge, 40.8% within 3 months, and 73.2% within one year (Forte et al., 2019). Adequate and immediate follow-up care is critical, and can significantly reduce the risk of subsequent attempts and suicides (Gould et al., 2018).
Psychological: Some factors, such as personality traits, thinking styles, and coping skills have also been associated with increased risk of suicide (APA, 2003). These psychological factors include:
- Thought constriction
- Polarized (either-or) thinking
- Incapacity for reality testing
- Inability to tolerate rejection
- Subjective loneliness
- Intolerable psychological pain
Medical: Certain medical conditions have also been associated with an increased risk for suicide. Chronic or terminal illness places patients at higher risk. For example, having chronic pain doubles the risk of completed suicide (Racine, 2018; Tang & Crane, 2006). Persons with these conditions can be assessed for suicide so as to inform a treatment plan (Jacobs, 2000).
|Medical Conditions Associated with Suicide Risk|
Moreover, patients with pain and an opioid use disorder can be at particularly high risk of suicide. An unexpected finding is that the number of firearm suicides in this population is even greater than the number of overdose suicides (Oquendo & Volkow, 2018). Screening patients with substance use disorders for suicide risk and, if present, addressing their access to all lethal means, often is indicated.
Firearms: Firearms account for approximately half of all suicides in the U.S. (CDC, 2020). Restricting access to or removing firearms can decrease suicides in at-risk populations. Studies suggest that individuals who live in a household with a firearm have at least a 3-fold increased risk of suicide (Anglemyer et al., 2014). The courts have affirmed that healthcare providers are permitted to ask patients about gun ownership, and counseling about gun safety, when indicated, is recommended by multiple medical societies, including the American Psychiatric Association and the American Academy of Family Physicians. Suicide is often impulsive: A significant proportion of suicides (24%-53%) are contemplated for as little as 5 minutes. Risk of suicide can be reduced if the firearms are kept unloaded and/or locked (Shenassa et al., 2004).
It is impossible to predict suicide in an individual. No study has ever shown that risk factors, either alone or in combination, can predict who will attempt or complete suicide, or when it might happen (Franklin et al., 2017). However, knowing the particular risk factors for an individual can help the clinician devise a tailored treatment plan, such as medication, psychotherapy, and treatment setting (including hospitalization). Moreover, researchers are currently studying whether machine learning algorithms, which can combine and weigh risk factors, might support assessment of suicidal risk with greater accuracy than current approaches. Preliminary results seem promising (American Psychological Association, 2016; Franklin et al., 2017).
Summary of Risk Factors for Suicide
(Adapted from SAFE-T, 2009)
Protective factors are those factors associated with protective effects for suicide.
Protective factors may buffer individuals from suicidal thoughts and behaviors. However, it must be emphasized that protective factors have not been studied as rigorously as risk factors and, even if present, may not counteract acute suicide risk (CDC; SAFE-T).
Suicide Screening Instruments and Rating Scales
In the past 10 years, some new rating scales have been developed, including the Columbia Suicide Severity Rating Scale (C-SSRS). The C-SSRS rates the degree of suicidal ideation on a scale, ranging from “wish to be dead” to “active suicidal ideation with specific plan and intent and behaviors” (Posner et al., 2011). It has gained widespread use in emergency rooms, hospitals, clinical research, and FDA trials. Research findings demonstrated that adults with prior suicidal behavior or suicidal intent were more likely to report suicidal behavior during several months of followup. These findings were ascertained with an electronic version of the C-SSRS and did not include suicide deaths (Mundt et al., 2013). When the C-SSRS or any other suicide risk rating scale is used for screening purposes, it can be accompanied by a complete and comprehensive suicide risk assessment to arrive at a clinical judgment of the level of risk (Fochtmann & Jacobs, 2015; Jacobs, 2016).
The Veteran Health Administration’s newly released guidelines recommend screening for suicide risk, but they do not recommend a specific instrument, as their review of the evidence did not identify a specific instrument or method that could reliably determine risk level. They recommend instead that clinicians use several methods to evaluate suicide risk—e.g., self-report measures combined with clinical interviews (Sall et al., 2019; USVA & DOD, 2019).
Examples of Suicide Assessment Instruments
The Suicide Inquiry
In 2016, the APA Work Group on Psychiatric Evaluation formulated practice guidelines for suicide risk assessment during an initial psychiatric evaluation. These guidelines contain a statement of intent that addresses the issue of standard of care. They recommend that a suicide risk assessment cover the following areas of inquiry:
- Current suicidal ideas, plans, and intent
- Prior suicidal ideas, plans, and attempts
- Prior intentional self-injury in which there was no known suicidal intent
- Current aggressive ideas or behaviors or psychotic delusions
- Mood, level of anxiety, thought content and process, and perception and cognition
- Anxiety symptoms, including panic attacks
- Past and current psychiatric diagnoses
- History of psychiatric hospitalization and emergency department visits for psychiatric evaluation
- Current or recent substance use disorder or change in use of alcohol or other substances
- Presence of psychosocial stressors (e.g., financial, housing, legal, educational, occupational, interpersonal/relationship problems, lack of social support, or painful, disfiguring or terminal illness)
- Trauma history
If a patient acknowledges current suicidal ideation, the APA Work Group on Psychiatric Evaluation (2016) recommended covering the following additional areas of inquiry:
- Patient’s intended course of action, if current symptoms worsen
- Access to suicide methods, including firearms
- Patient’s possible motivation for suicide (e.g., attention or reaction from others, revenge, shame, humiliation, delusional guilt, command auditory hallucinations)
- Reasons for living (e.g., responsibility to children, religious beliefs)
- Quality and strength of the therapeutic alliance
- History of suicidal behaviors in biological relatives
The APA Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors (2003) compiled a list of questions that may be helpful when inquiring about specific aspects of suicidal thoughts, plans, or behaviors. To access this table, click here. Additional areas of inquiry can include questions about feeling like a burden, lack of fear of death, and psychic pain.
PSYCHODYNAMIC ASSESSMENT OF SUICIDE RISK
By Glen O. Gabbard, M.D.
The psychodynamic assessment of suicide risk includes a detailed search into current relationships, stressors in the environment, losses, and injuries to one’s self-esteem (Gabbard, 2014). Specific psychodynamic themes involved with suicidality can be useful to consider. Is their anger turned inward? Does the patient feel that destructiveness or greed have harmed others who are loved? Is there a strong perfectionistic streak that leaves the patient feeling hopeless about achieving some impossible goals? Is there an unrelenting superego that makes them feel they are never able to perform at their best level? Have they experienced a painful loss of someone who was loved? Have they experienced a recent narcissistic injury that is extraordinarily shame-inducing? Is there someone the patient wants to “get back at” associated with intense grievances (Menninger, 1933)?
Evaluators can empathize with the painfulness of the patient while also enlisting the patient’s help in a collaborative search for its underlying causes. Careful listening and empathizing are strategies that facilitate important connection (Havens, 1965).
In addition to listening, the professional who is assessing patients for suicide must also look for nonverbal indicators of suicidality. For example, how a patient answers the question, “Are you thinking about suicide?” may provide highly relevant information. If there is a long pause, and the patient finally responds with a succinct “no,” further inquiry may be needed. Conversely, if the patient is too vigorous in denying any risk, one can probe further into what appears to be an automatic denial. A straightforward confrontation, such as “Are you really telling me the truth?” can sometimes be powerful and lead to an acknowledgment that there is more to the story.
Countertransference is a common issue in evaluations of suicidality. Clinicians who are aware of their own internal state as they are monitoring the patient’s condition can reduce a potential barrier to the challenging task of the assessment of suicide risk.
Glen O. Gabbard, M.D. is Clinical Professor of Psychiatry at Baylor College of Medicine and Training and Supervising Analyst at the Center for Psychoanalytic Studies in Houston.
Determination of Risk Level and Intervention
Mental health clinicians use clinical judgment to determine a patient’s level of suicidal risk and corresponding intervention.
Persons considered to be at high risk for suicide include those who have made a potentially lethal suicide attempt or have a strong intent to die. High risk patients also may have psychiatric disorders or have experienced an acute precipitating event. In contrast, those deemed to be at low risk for suicide may have thoughts of death, but no plan, intent, or self-injurious behavior. Low risk patients often have modifiable risk factors and strong protective factors (Jacobs, 2016).
Clinical judgment regarding the overall level of risk and appropriate intervention also depends on the patient’s cognitive capacity and reasoning, ability to control impulses, and accept and adhere to treatment. The clinician may take into account the acuteness or chronicity of the patient’s suicidal status and their ability to sustain or form a therapeutic alliance (Jacobs et al., 1999). A recent systematic review has shown that a strong therapeutic alliance is associated with fewer suicidal thoughts and self-harming behaviors (Dunster-Page et al., 2017).
Treatment Setting and HOSPITALIZATION
This section discusses selecting a treatment setting for at-risk patients, including situations where hospital admission may be warranted. The information is from Table 8 of the American Psychiatric Association’s Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors (APA, 2003).
Hospital admission is generally indicated…
After a suicide attempt or aborted attempt if:
- Patient is psychotic
- Attempt was violent
- Precautions were taken to avoid rescue or discovery
- Persistent plan and/or intent is present
- Distress is increased or patient regrets surviving
- Patient is male, older than 45 years, especially with new onset of psychiatric illness or suicidal thinking
- Patient has limited family and/or social support, including lack of stable living situation
- Current impulsive behavior, severe agitation, poor judgment, or refusal of help is evident
- Patient has change in mental status with a metabolic, toxic, infectious or other etiology requiring further workup in a structured setting
In the presence of suicidal ideation with:
- Specific plan with high lethality
- High suicidal intent
Hospital admission may be necessary…
After a suicide attempt or aborted attempt, except in circumstances for which admission is generally indicated
In the presence of suicidal ideation with:
- Major psychiatric disorder
- Past attempts, particularly if medically serious
- Possibly contributing medical condition
- Lack of response to or inability to cooperate with partial hospital or outpatient treatment
- Need for supervised setting for medication trial or ECT
- Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting
- Limited family and/or social support, including lack of stable living situation
- Lack of an ongoing clinician-patient relationship or lack of access to timely outpatient follow-up
In the absence of suicide attempts or reported suicidal ideation/plan/intent, but evidence from the psychiatric evaluation and/or history from others suggest a high high level of suicide risk and a recent acute increase in risk
Release from emergency department with follow-up recommendations may be possible…
After a suicide attempt or in the presence of suicidal ideation/plan when:
- Suicidality is a reaction to precipitating events (e.g., exam failure, relationship difficulties), particularly if the patient’s view of situation has changed since coming to emergency department
- Plan/method and intent have low lethality
- Patient has stable and supportive living situation
- Patient is able to cooperate with recommendation for follow-up, with treater contacted, if possible, if patient is currently in treatment
Outpatient treatment may be more beneficial than hospitalization…
If patient has chronic suicidal ideation and/or self injury without prior medically serious attempts, and if a safe and supportive living situation is available and outpatient psychiatric care is ongoing
Current evidence-based treatments for reducing suicide risk include medication, brain stimulation techniques, and psychotherapy. Some newer treatments can be very helpful for those who have been struggling with depression that has not responded to other treatments or who need rapid treatment intervention. As all treatments can have side effects, clinicians use a risk-benefit estimation to guide treatment.
Antidepressants: The FDA has approved many medicines for treatment of depression, notably the antidepressants. Antidepressants can reduce suicidal thoughts in patients as depression improves, but they require time to take effect. Most patients experience significant improvement within three months of antidepressant treatment, usually with some benefit within the first month. Antidepressants must be taken consistently and at adequate doses.
The currently most frequently prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs). They are effective, have a favorable side-effect profile, and are unlikely to be lethal on overdose. Examples include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).
Other types of antidepressants include serotonin and noradrenaline reuptake inhibitors (SNRIs; e.g., duloxetine, levo-milnacipran, and venlafaxine), tricyclics (e.g., amitriptyline, desipramine, imipramine, and nortriptyline), monoamine oxidase inhibitors (MAOIs; such as phenelzine and tranylcypromine) and some with other action mechanisms (e.g., bupropion and mirtazapine).
|Common Reasons Patients May Not Experience Improvement with Antidepressant Treatment|
There is inconsistent evidence about effects of antidepressant treatment and suicidal risks. One would expect that treatments that are effective for depression should reduce suicidal risk. However, compelling evidence of reduction of rates of suicide attempt and suicide during antidepressant treatment is lacking, although suicidal ideation typically decreases, usually along with improvement of other symptoms of depression. Some patients may become excited, irritable, sleepless, and so are potentially more suicidal during treatment with antidepressants.
Moreover, the FDA requires all antidepressants to carry a black-box (severe) warning that persons under age 25 years may experience new or increased thoughts of suicide, especially when first starting treatment. Careful monitoring of suicidal status in patients taking an antidepressant is important, not only to detect early clinical changes that may include increased suicidal risk, but also because antidepressants can unmask previously undiagnosed bipolar disorder, which requires a different treatment approach.
Antianxiety agents: Since anxiety is a significant and modifiable risk factor for suicide, use of antianxiety agents may decrease this risk. More specifically, in the presence of depression, acute suicidal risk may be associated with psychic anxiety, panic attacks, agitation, and insomnia (Fawcett et al., 1990). These symptoms might be reduced by short-term benzodiazepine treatment (1–4 weeks). However, research on suicide risk with antianxiety treatment is very limited, and findings from randomized, controlled trials are lacking. To minimize severe recurrent or rebound anxiety or agitation, long-acting benzodiazepines may be preferable to short-acting ones, although long-acting benzodiazepines are more likely to cause daytime sedation. Persistent, severe insomnia is also a modifiable risk factor for suicide and can be addressed with the use of a benzodiazepine, a sedating second-generation antipsychotic (Londborg et al., 2000; Smith et al., 1998; Smith et al., 2002), or a sedating antidepressant, such as mirtazapine (APA, 2003).
In treating potentially suicidal patients, benzodiazepines are sometimes avoided because of concerns about their potential for inducing dependency (Salzman, 1998), respiratory depression, or behavioral disinhibition. Such adverse responses appear to be particularly likely among patients with borderline personality disorder or cognitive dysfunction (Cowdry & Gardner, 1988; Dietch & Jennings, 1988; Gardner & Cowdry, 1985; Kalachnik et al., 2002; O’Sullivan et al., 1994). Nevertheless, the risk of such adverse effects appears to be small (Rothschild et al., 2000). Since benzodiazepines can limit psychic distress in depressed patients and improve sleep, they can potentiate clinical benefits of antidepressant treatment (Londborg et al., 2000; Joughin et al., 1991; Smith et al., 1998; Smith et al., 2002). In general, decisions about initiating or continuing benzodiazepines in suicidal patients should consider the preceding potential risks and benefits as they relate to individual patients (APA, 2003).
In short, it is clinically appropriate to provide treatments aimed at reducing anxiety, psychic distress, agitation, and insomnia, regardless of the primary diagnosis, as part of a comprehensive effort to limit suicide risk. Antianxiety agents may have a useful empirical role in such situations, when employed with due regard to their risk of disinhibiting impulsive or aggressive behavior (APA, 2003; Fawcett, 1988).
Lithium: Researchers have found that long-term maintenance treatment with lithium reduces suicide risk in patients with bipolar I disorder, bipolar II disorder, and possibly unipolar depressive disorder. In bipolar disorder patients, suicide risk during lithium treatment maintenance therapy became similar to that in the general population in one study (Tondo & Baldessarini, 2009). Lithium may provide this benefit by reducing dysphoric-agitated symptoms, aggression, and impulsivity. Lithium is given cautiously because amounts that are three or more times the typical or standard dose can be toxic or even lethal.
There also is evidence that lithium may be superior to other mood stabilizing agents in reducing suicide attempts in bipolar disorder patients, notably compared to carbamazepine or valproate (Baldessarini & Tondo, 2009; Fazel & Runeson, 2020; Song et al., 2017). A recent study found that juveniles being treated with lithium had half as many suicide attempts, improved depressive symptoms, less psychosocial impairment, and less aggression (Hafeman et al., 2019). Click here for additional references on the topic of lithium and suicide risk.
Other Mood-Stabilizing Agents: Evidence for a protective effect against suicide of “mood-stabilizing” agents other than lithium is limited. Studies show that patients have fewer suicide attempts and suicides when treated for bipolar disorder with lithium than with carbamazepine (e.g., Tegretol) and divalproex (e.g., Depakote), neither of which is approved as effective for long-term, maintenance treatment of bipolar disorder patients. Goodwin and colleagues (2003) found, for example, that the risk of suicide was 2.7 times higher when treated with these two medicines than with lithium, after controlling for potential confounds. The risk of suicide attempts resulting in emergency department care was 1.7 times higher for patients treated with these two anticonvulsants than with lithium (APA, 2003; Goodwin et al., 2003).
There is even more limited information on risks of suicide and suicide attempts during treatment with other mood-stabilizing agents aside from lithium, notably carbamazepine, and divalproex. This is despite the growing use of anticonvulsants and some second-generation antipsychotics for the treatment of bipolar disorder because of their relative simplicity of use as well as rapid efficacy in treating mania. Thus, when weighing the risks and benefits of various medications for bipolar disorder, the efficacy of lithium in decreasing suicidal behavior should be taken into consideration (APA, 2003).
Ketamine: Low intravenous doses of ketamine can rapidly reduce suicidal thoughts even in patients with otherwise treatment-resistant depression in both major depressive and bipolar disorders (Wilkinson et al., 2018) and led to a greater reduction in suicidal thoughts than low-doses of the sedative midazolam (Grunebaum et al., 2018). Reduction in suicidal thoughts after ketamine lasted as long as 6 weeks, with additional improvements in depressed mood and fatigue. Intranasal esketamine requires 2 hours of monitoring before discharge.
Clozapine: Approximately 50% of patients who have schizophrenia or schizoaffective disorder attempt suicide. Estimates suggest that about 5%–10% die of suicide (Meltzer et al., 2003; Palmer et al., 2005). Clozapine is the only medication approved by the FDA for “reducing suicidal behavior” and only in patients diagnosed with schizophrenia. In general, clozapine is used for patients with schizophrenia or schizoaffective disorder who have not been helped by other treatments or who have tried to kill themselves and are likely to try again, regardless of their previous responses to treatment. Clozapine is available only through a restricted distribution and monitoring program to limit risks of potentially lethal aganulocytosis.
Clozapine is an old drug, but widely considered to be the first of a class designated as “second-generation” or atypical antipsychotics, reflecting their far lower risk of adverse neurological effects that were typical of the early antipsychotics, including the phenothiazines, thioxanthenes, and haloperidol. Clozapine produces complex changes in brain chemistry and its special status as one of the most effective treatments for psychotic illness remains unexplained.
Evidence that treatment of schizophrenia patients with clozapine substantially reduces their risk of suicidal behavior is quite secure (Masuda et al., 2019), including a randomized trial that found it more effective than olanzapine (Meltzer et al., 2003). There is no evidence that clozapine treatment reduces suicidal risk in depressive disorders and it remains poorly studied in bipolar disorder.
Other Antipsychotic Agents: While first-generation antipsychotics (e.g., fluphenazine, thiothixene, and haloperidol) are very effective in treating psychotic symptoms (delusions, hallucinations, agitation, aggression, and confusion), studies have found them to be less effective in treating suicide risk than clozapine (Taipale et al., 2020; APA, 2003). They are also associated with prevalent adverse side effects, including extrapyramidal neurological side effects, akathisia, and possibly also worsening of depression. Because of this, they have been replaced over time in the United States by second-generation antipsychotics, which have lower risks of most extrapyramidal adverse effects, but can induce akathisia, which can be a risk factor for suicide (APA, 2003; Meltzer & Okayli, 1995; Walker et al., 1997).
Studies found that the risk of suicide in patients with schizophrenia was 57% lower among those treated with clozapine than those treated with haloperidol (Glazer, 1998; Glazer & Dickson, 1998). In another study, Spivak and colleagues (1998) compared 30 patients with chronic, treatment-resistant schizophrenia who had been maintained on clozapine for at least 1 year with an equal number of patients who had been treated with first-generation antipsychotics for similar lengths of time. They found that clozapine treatment was associated with fewer suicide attempts. Because of clozapine’s efficacy in reducing suicide risk, the use of first-generation antipsychotics in suicidal patients is specifically reserved for those whose psychosis has not responded to a second-generation antipsychotic, or those for whom economic considerations encourage use of less expensive drugs (APA, 2003).
However, clozapine treatment has also been associated with some potentially serious adverse effects, including seizures, weight gain, hyperlipidemia, type II diabetes, agranulocytosis, cardiomyopathy, myocarditis, ileus, and rare atypical forms of a syndrome similar to neuroleptic malignant syndrome, which can also reduce longevity. Thus, in clinical practice, the evident advantage of clozapine in reducing the rate of suicide attempts and perhaps the rate of suicide must be weighed against the risks of death from these adverse effects (Glazer, 1998). Therefore, when deciding whether to institute or continue clozapine treatment in patients with psychosis who are at risk for suicidal behaviors, the clinician will need to weigh the advantages and disadvantages of clozapine therapy for the individual patient (APA, 2003).
Hypnotics: Although the use of hypnotics is not generally recommended, a recent randomized controlled trial compared a hypnotic in combination with an SSRI to placebo and found that the combined medications reduced suicidal ideation in suicidal adults with insomnia. The authors suggest that prescribing controlled-release zolpidem when starting SSRI antidepressant treatment may be beneficial for suicidal patients with severe insomnia. It is known that severe insomnia is a risk factor for suicide (McCall et al., 2019).
Medication for Addiction Treatment
Twenty-five percent of people who die by suicide are misusing or dependent on alcohol or drugs. Those who use opioids regularly are two times more likely to attempt suicide than those who do not report any opioid use. Those who use opioids regularly are also 75% more likely to make a suicide plan (www.opioidscreening.org).
Medication for addiction treatment (MAT) for opioid use disorder has been associated with a decreased rate of suicide. Opioid-dependent individuals who used methadone or buprenorphine to treat their addiction exhibited less suicidal behavior and lower rates of crime (Ahmadi et al., 2018; Fazel & Runeson, 2020; Molero et al., 2018; Yovell et al., 2015).
For more information about effective treatments for opioid use disorder and the relationship between opioid use disorder and suicide risk, please visit www.opioidscreening.org
Brain Stimulation Techniques
Electroconvulsive Therapy (ECT): Electroconvulsive Therapy (ECT) is one of the most effective treatments for patients with treatment-resistant depression or severe depression with psychotic features. It involves applying a brief electrical stimulation to the brain to induce a generalized seizure, while a patient is under anesthesia and given a muscle-relaxant to avoid injury. In the U.S,, most ECT is now given on an outpatient basis. ECT is used for severe cases when other treatments (including medication and psychotherapy) have failed to yield adequate responses (APA, 2001).
ECT is also used for suicidal patients who require a rapid treatment intervention. ECT can rapidly reduce suicidal ideation (Watson, 2019). Over 60% of patients with major depressive disorder achieve remission by the third week of treatment with ECT, though many experience relapse within the following 6 months. Accordingly, most people treated with ECT require some form of maintenance treatment (e.g., psychotherapy, medication, additional ECT), which is not surprising for lifelong, recurring illnesses.
Repeated Transcranial Magnetic Stimulation (rTMS): Repeated Transcranial Magnetic Stimulation (rTMS) is sometimes used to treat patients with major depressive disorder who do not respond to one or more adequate trials of antidepressants. rTMS uses magnetic stimulation to activate selective brain sites without inducing a generalized seizure.
rTMS may resolve suicidal ideation in some patients with treatment-resistant depression. In one study, bilateral, left-unilateral, and sham rTMS were evaluated for effects on suicidal ideation (Weissman et al., 2018). It resolved in 40.4% of patients exposed to bilateral rTMS, 26.8% with left-unilateral rTMS, and 18.8% with sham rTMS, indicating superiority of bilateral treatment.
Although rTMS does not seem to be as effective as ECT, it does not require anesthesia and has far less adverse effects on memory and cognition, and bilateral rTMS may be a useful alternative for suicidal ideation when ECT is declined, not tolerated, or not readily available.
Magnetic Seizure Therapy (MST): In this relatively new intervention for patients with treatment-resistant depression, a therapeutic seizure is induced by magnetic stimulation of the brain at higher frequencies than are used in rTMS. Patients given MST are anesthetized and given a muscle-relaxant to avoid injury similar to the protocol for ECT. MST can reduce suicidal ideation in some patients with treatment-resistant depression: In one study 44.4% of patients treated with MST experienced resolution of suicidal ideation (Sun et al., 2018).
In addition to pharmacotherapies and brain stimulation techniques, psychotherapies play a central role in the management of suicidal behavior in clinical practice. Psychotherapy is often used to treat patients who have suicidal thoughts or who have made suicide attempts. Evidence-based treatments include cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), and mindfulness-based cognitive therapy (MBCT). Although there is limited research, clinical consensus suggests that psychodynamic and interpersonal therapy can be of significant benefit, even if there are fewer studies. Psychotherapy can be used by itself, but typically in conjunction with medication treatment.
Cognitive Behavioral Therapy (CBT): CBT is a psychological treatment that addresses faulty or unhelpful thoughts and behaviors. The goal is to build skills to better cope with distress. CBT can reduce suicidal ideation, attempts, and hopelessness (D’Anci et al., 2019). CBT appears to be especially effective in reducing suicidal behavior when the treatment specifically targets suicidal thoughts and behaviors (as opposed to thoughts and behaviors related to depression or mental illness in general).
Dialectical Behavioral Therapy (DBT): DBT combines methods of CBT with skills-training and mindfulness meditation techniques to improve emotion regulation, interpersonal relationships, and ability to tolerate distress. DBT was originally developed as a treatment for suicidal behavior in women with borderline personality disorder, but has since shown effectiveness for other disorders, including mood disorders, eating disorders, substance misuse, and PTSD. Several recent studies have found DBT to be an effective treatment for reducing repeat suicide attempts in highly suicidal patients, including adolescents (McCauley et al., 2018). A cornerstone of DBT is the idea that the patient must build a life worth living, even when the patient has many problems and wishes to die. Click here for some recommended online DBT skills training courses.
Mindfulness-Based Cognitive Therapy (MBCT): This form of psychotherapy integrates mindfulness meditation practices and cognitive therapy techniques. A growing body of evidence indicates that training in mindfulness can help break the link between depressive symptoms and suicidal thinking. In addition, MBCT can protect against depressive relapses that are common in those with a history of suicidal ideation and behaviors (Barnhofer et al., 2015).
Psychodynamic psychotherapy: Psychodynamic psychotherapy helps patients to improve self-esteem and interpersonal relationships by understanding and working through the way in which past experiences have shaped current feelings and behavior. There is increasing evidence that psychodynamic therapies are effective for a wide range of mental health conditions, and that they can help to reduce suicidal behavior. Psychodynamic psychotherapists often integrate techniques from CBT and DBT in an empathic frame that is flexible in addressing the patient’s problems (Schechter et al., 2019).
A suicide safety plan is a written, individualized list of coping strategies and resources that can help a person know what to do when they are experiencing an acute suicidal crisis (Stanley & Brown, 2012).
This collaborative plan between the clinician and patient is a living document that can be modified over time as circumstances change. The safety plan typically covers the following areas:
- Recognizing warning signs of suicide risk in oneself
- Employing internal coping strategies without needing to contact another person
- Socializing with others who may offer support as well as distraction from the crisis
- Contacting family members or friends who may help resolve a crisis
- Contacting mental health professionals or agencies
- Reducing the potential for use of lethal means
Safety plans are different from no-suicide contracts, which were frequently used in the past, but had limited usefulness and depended on a strong therapeutic alliance. However, there is evidence that safety plans work. A recent study found that safety planning with telephone follow-up reduced suicidal behaviors over a 6-month period by 45% (Stanley et al., 2018).
Some clinicians and hospitals have been using mobile safety planning apps in addition to, or in lieu of, written safety plans. Many of these apps are free of charge and publicly available, such as the Safety Plan, which was developed by the New York State Office of Mental Health with permission from Stanley and Brown. Preliminary data evaluating the effectiveness of safety planning smartphone apps is encouraging (e.g., Melvin et al., 2019).
Brief Suicide Interventions and Continuity of Care
A recent meta-analysis has found that brief interventions can actually reduce suicide attempts. The study looked at interventions that could be administered during just one acute care encounter (Doupnik et al., 2020).
Brief interventions include not only the safety planning intervention discussed in the section above, but also follow-up phone calls, post cards, or letters to remind the patient to follow up with outpatient care. Another type of brief intervention is care coordination, such as scheduling an appointment or a mobile crisis response team evaluation, or delivering a warm handoff to another mental health clinician. The primary goal of most of these interventions is to promote connectedness between the suicidal patient and another mental health clinician, or between the patient and their community or family (Doupnik et al., 2020).
Suicidal patients often have difficulty with treatment compliance after discharge from acute care settings. Indeed, only around one-third of patients who have an outpatient appointment scheduled within one week of discharge follow through with that appointment (Melhem & Brent, 2020). The meta-analysis shows that brief interventions can reduce suicide attempts and increase linkage to care (Doupnik et al., 2020; Melhem & Brent, 2020).
Zero Suicide is an initiative that aims to reduce suicide through creating systematic changes in health and behavioral health care systems. The priority is keeping both patients and clinical staff safe and supported. The initiative focuses on identifying suicide risk, evidence-based interventions, quality improvement, and continuing care and support for those seeking help. The website contains a toolkit and other resources that may be helpful to those who provide care to suicidal patients.
The term “postvention” was coined in 1972 by Edwin Schneidman, the founder of the nation’s first comprehensive suicide prevention center (Schneidman, 1973). The term refers to interventions that are conducted after a suicide death to support those who have been affected, including family, friends, coworkers, or classmates. Those grieving a suicide often receive less community support for their loss than those grieving deaths by other means, which can lead to isolation (Pitman et al., 2014). One of the main purposes of postvention is to offer comfort and support to the bereaved, and potentially reduce the aftereffects of a suicide.
One in every 5 people report exposure to a suicide during their lifetime (Andriessen et al., 2017). Those who have been exposed to a suicide are at a significantly increased risk of suicide. For example, those who experience the suicide death of a first-degree relative are 3 times more likely to complete suicide themselves. Those whose spouses died by suicide have between 3 and 16 times increased suicidal risk (Agerbo, 2005). Men who have been exposed to suicide in the workplace are 3.5 times more likely to die by suicide than those not exposed (Hedstrom, Liu, & Nordvik, 2008).
One study found that 4.5-7.5 immediate family members and 15-20 extended family, friends, and colleagues were “intimately and directed affected” by a suicide (Berman, 2011). The box below indicates that friends, family, and others who were emotionally close to the deceased are likely to require support and postvention services (Berkowitz et al., 2011). One study found an increased incidence of depression, anxiety, and post-traumatic stress disorder (PTSD) in adolescents exposed to the suicide of a peer (Brent et al., 1996). Another study found that, without early intervention, a significant proportion of prepubertal children who had lost a sibling or a relative to suicide were likely to go on to develop major depression or PTSD (Pfeffer et al., 1997).
|Those Most Likely to Need Support Following a Suicide|
(Berkowitz et al., 2011)
Research shows that those who knew about the deceased’s suicide plans are at greater risk of PTSD and depression, and that those who had witnessed the suicide or viewed the scene afterward are at greater risk of PTSD and anxiety (Brent et al., 1996). Adverse mental health outcomes following a suicide are also more common among those who have a psychiatric disorder or a family history of psychiatric disorder, particularly a mood disorder (Andriessen et al., 2019; Pitman et al., 2016).
|Mental Health Effects of Suicide Exposure|
The goals of postvention are to assist with the grieving process, stabilize the environment, reduce the risk of contagion or suicide clusters, and identify and treat mental health problems among survivors. Providers of postvention typically emphasize that suicide is multifactorial, not the result of a single factor or event. They also emphasize that there are alternatives to suicide when one is feeling depressed and hopeless, that suicide is a permanent solution to a temporary problem, and that there are resources available in the community for getting help. Providers also use the forum to provide psychoeducation on grieving, depression, PTSD, suicide, and means reduction (Berkowitz et al., 2011).
Andriessen and colleagues (2019) examined the effectiveness of interventions for people who had been bereaved through suicide. The most promising interventions were those led by a trained facilitator, that included supportive, therapeutic, and educational approaches, and that met regularly for an appropriate period of time.
This section recognizes special issues in suicide assessment and intervention, such as age, hospitalization, and the perinatal period. It also addresses the heightened risk of suicide among certain professions, such as military personnel and healthcare workers. The section concludes with a list of resources that clinicians may find helpful when dealing with suicidal patients.
Children and Adolescents
Record numbers of children and adolescents have been presenting to emergency departments for mental health issues, especially for deliberate self-harm and substance use. A recent study found that while the total number of ED visits for children aged 5 to 17 years remained stable between between 2007 and 2016, there was a 60% increase in pediatric ED visits for mental health disorders, a 159% increase in visits for substance use disorders, and a 329% increase in visits related to deliberate self-harm (Lo et al., 2020).
Youth Suicide Warning Signs (adapted from Youth Suicide Warning Signs)
In 2013, an expert panel met at SAMSHA headquarters in Rockville, Maryland to review literature and develop a consensus list of warning signs for youth suicide. The following warning signs for youth suicide were established at that meeting.
The following signs may mean that a youth is at risk for suicide, particularly in youth who have attempted suicide in the past:
- Talking about or making plans for suicide
- Expressing hopelessness about the future
- Displaying severe/overwhelming emotional pain or distress
- Showing worrisome behavioral cues or marked changes in behavior, particularly in the presence of the above warning signs. Specifically, this includes significant:
- Withdrawal from or change in social connections/situations, including extracurricular activities and school performance
- Changes in sleep (increased or decreased)
- Anger or hostility that seems out of character or out of context
- Recent increased agitation or irritability
- Risk taking behavior or alcohol/drug use
Risk is greater if the warning sign is:
- has increased
- related to an anticipated or actual painful event, loss, or change
- associated with the acute onset of mental illness
The presence of more than one of these warning signs may increase a youth’s risk for engaging in suicidal behaviors in the near future.
The National Institute of Mental Health (NIMH) has developed a Brief Suicide Safety Assessment Guide to be used with patients aged 10-24 years old.
Children and adolescents under the age of 18 can be interviewed together with a parent or guardian, if one is available. For patients who are 18 years of age or older, the patient’s permission is necessary in order for the parent or guardian to join the interview (this varies by state: in some states the minimum age for self-consent is 16). The parent or guardian can also be involved in creating a safety plan for managing suicidal thoughts that may arise in the future.
Suicide risk assessments of adolescents and young adults, especially those with a mood disorder, typically include questions about the presence of non-suicidal self-injury (NSSI), as NSSI has been associated with suicide attempts in this population and others. The assessment for NSSI may include questions about the presence of intent to die, the function of or reasons for engaging in the behavior, methods used, frequency and severity of past self-injurious behavior, and the presence of plan and intent to engage in future self-injury (Nock et al., 2006).
The exact rate of suicide among college students is not entirely clear. However, the rate of suicide appears to be lower among college students than their non-student peers (Arria et al., 2009). Male students older than 25 showed particularly high rates of suicide, and graduate students have higher rates of suicide than undergraduate students (Haas et al., 2003).
- More readily available no or low-cost health insurance on campus
- More supportive peer and mentor environment on campus
- Campus prohibitions on the availability of firearms
- Greater restriction and monitoring of alcohol use on campus
- Clearer sense of purpose among college students
- Relative freedom students have from the daily hassles of living
However, the incidence of suicide among college students is difficult to interpret from individual studies due to variations between studies in the definition of a “college suicide.” Some studies identified only those suicides that took place on campus, whereas others would include all suicides that occurred while the student was enrolled, regardless of the actual location of the suicide. Some studies have been criticized for not distinguishing full-time from part-time students and for not including former students who fail to graduate. In longitudinal studies, dropping out of college has been associated with a greatly increased risk of suicide (Haas et al., 2003).
The 2008 American College Health Association assessment of 26,685 students in 40 postsecondary institutions found that 1.3% of college students had attempted suicide and 6.4% had seriously considered suicide at least once in the past 12 months (Wilcox et al., 2010).
Risk Factors for Suicide in College Students
|Risk Factors for Suicide in College Students|
Suicide in college students, like suicide in other population samples, is always multifactorial (APA, 2003).
Most mental disorders have their first onset by age 24. College students are in the high-risk age group (18 to 25 years) for the manifestation of symptoms of the more common mental health disorders, including depression, schizophrenia, anxiety, and substance abuse problems (Cook, 2007). The 15-21 age category (which are typically the college years) has the highest past-year prevalence rate of mental illness (Mackenzie et al., 2011).
Nyer et al. (2013) examined potential factors that may distinguish college students with depressive symptoms and suicidal ideation from those college students with depressive symptoms but no suicidal ideation. The sample was composed of 287 undergraduates with total scores greater than 13 on the Beck Depression Inventory. They found that the suicidal students were more symptomatic than the non-suicidal students (i.e., they had significantly higher levels of depressive symptoms, hopelessness, and anxiety). However, contrary to expectations, the non-suicidal and suicidal students did not differ on measures of cognitive and physical functioning or grade point average. These findings highlight the importance of monitoring and treating comorbid symptoms of anxiety when students present with depressive symptoms, as well as the importance about asking about suicidal ideation even when a student may not appear functionally impaired. Nyer et al. (2013) state: “Lack of functional impairment in students with SI may be one of the reasons why suicide of young people appears to occur unexpectedly” (p. 7).
Alcohol and substance use has been linked to suicide ideation and suicide attempts in college students (Arria et al., 2009). Eighty percent of college students drink alcohol, and half of college student drinkers engage in heavy episodic drinking (Lamis et al., 2009). College students who binge drink in solitary contexts (i.e., while alone) experience greater depression and suicidal ideation than students who only binge drink in social contexts (Gonzalez, 2012). Studies have found evidence of alcohol/substance abuse in 38 to 54 percent of adolescent and young adult suicide victims (Miller & Glinski, 2000). In addition, prescription opioid use has been correlated with suicidal ideation and attempts in college student samples (Zullig & Divin, 2012).
While the rate of suicide among Asian Americans in the general population is lower than average, this does not appear to be the case among Asian American college students, who report higher levels of suicidal ideation and attempts than their White American counterparts (Wong et al., 2011). One national study found that the odds of seriously considering attempting suicide were 1.6 times higher for Asian American students compared with White American students (Kisch et al., 2005; Wong et al., 2011). Wong et al. (2011) found that suicidal ideation in their sample of Asian-American college students was associated with perceived burdensomeness and thwarted belongingness. Additionally, fewer than 7% of the Asian American participants in their sample attributed the cause of suicidal ideation to psychological distress, whereas 80% of participants attributed it to an interpersonal issue.
Some other student groups that have elevated rates of suicide include students with learning disabilities, who have been found to be twice as likely as other college students to attempt suicide (Svetaz et al., 2000; Shadick & Akhter, 2014), and LGBTQ+ students, who have significantly higher rates of suicidal ideation and attempts than heterosexual peers (Shadick & Akhter, 2014).
Intimate partner or physical dating violence also increase risk for suicide in college students (Daniels, 2005). Mackenzie et al. (2011) found that unwanted sexual encounters and a history of physical violence were associated with depression in their college health clinic sample. Blosnich and Bossarte (2012) found that gay and lesbian college students who experienced any intimate partner violence in the past 12 months had greater than twice the odds of suicidal ideation in the past 12 months compared with gay and lesbian students who did not experience intimate partner violence. Clinicians should screen for intimate partner violence to assure that students are not placed back into a dangerous situation, an abusive partner is not mistakenly cited as a source of social support, and referral to additional services can be offered (Blosnich & Bossarte, 2012). Please be aware that many people may feel uncomfortable disclosing intimate partner violence even though this presents a problem in their lives that needs to be addressed (Daniels, 2005). Another area of inquiry in the young adult population are text and social media communications and other forms of cyberbullying. Some recent criminal cases in Massachusetts have uncovered abusive text messages and phone calls contributing to suicide (e.g., Andersen, 2019).
In addition, clinicians who see college students can assess for parent-child conflict and, if relevant, address this issue in therapy. Since college students are young adults and are often not living with their parents, it may be easy for clinicians to overlook this issue (Lamis and Jahn, 2013).
Summary of Suicide Risk Factors in College Students
The Suicide Prevention Resource Center (SPRC) has a fact sheet titled “Suicide among College and University Students in the United States” which summarizes the risk factors factors in this population (SPRC, 2014):
- Behavioral health issues/disorders: Depression; substance use; conduct disorders; other disorders (anxiety, eating disorders); previous suicide attempts; NSSI.
- Individual characteristics: Hopelessness, loneliness, social isolation, lack of belonging, anger/hostility; risky behavior, impulsivity; low stress and frustration tolerance; poor problem-solving or coping skills; perception of being a burden.
- Adverse/stressful life circumstances: Interpersonal difficulties or losses (e.g., relationship breakup, dating violence); school or work problems; financial problems; physical, sexual, and/or psychological abuse (current and/or previous); chronic physical illness or disability.
- Family characteristics: Family history of suicide or suicidal behavior; parental mental health problems; family violence or abuse (current and/or previous); family instability and/or loss; lack of parental support.
- School and Community Factors: Limited access to effective health or mental health treatment; stigma associated with seeking care; negative social and emotional environment (negative attitudes, beliefs, feelings, interactions of staff and students); discrimination based on sexual orientation, gender identity, race and ethnicity, or physical characteristics (e.g., being overweight); access to lethal means; exposure to media normalizing or glamorizing suicide.
The majority of students who die by suicide do so without ever entering a therapist’s office (Eisenberg et al., 2012). One study, for example, found only 23% of college students who committed suicide had been seen by their college counseling center (Cukrowicz et al., 2011; Schwartz, 2006). Treatment use in the college population is higher among women, White students, and those who have friends or family members who have been in treatment (Eisenberg et al., 2012; Masuda et al., 2009). Indeed, the Healthy Minds Study found that 40% of white students with mental health problems received treatment compared to 28% of Hispanic students, 26% of Black students, and 15% of Asian students (Eisenberg et al., 2012). International students are also less likely than domestic students to seek counseling (Shadick & Akhter, 2014). Those with close friends or family members in treatment were more likely to seek help for themselves (Eisenberg et al., 2011; 2012).
One reason cited for not seeking help was the cultural competence of mental health services. In the Healthy Minds Study, 9% of non-White students cited “People providing services aren’t sensitive enough to cultural issues” as an important reason for not receiving services. Twenty-three percent of students with sexual orientations other than heterosexual cited “People providing services aren’t sensitive enough to sexual identity issues.” Other common barriers to seeking help were “I don’t have time,” “I prefer to deal with these issues on my own,” “Stress is normal in college/graduate school,” and “I question how serious my needs are” (Eisenberg et al., 2012). For resources on providing culturally-competent care, please see the “Race, Ethnicity, and Culture” section below.
|Risk Factors for Suicide in the Elderly|
Elderly populations show lower rates of suicide attempts, but higher rates of suicide completion. They tend to choose more lethal methods, display fewer warning signs, and appear to be more determined to die than younger persons.
Approximately 80% of suicide decedents have had contact with a primary care physician in the last year before death (Stene-Larsen & Reneflot, 2019; Walby et al., 2018), and 45% in the last month (Conejero et al., 2018; Luoma et al., 2002). Elderly patients often have physical ailments, and, therefore, are especially likely to visit a doctor. Thus, primary care providers may be strategically positioned to help in reducing risk of suicide in the elderly by being attuned to common risk factors in this population.
Integrated care is the coordination of primary and behavioral health care. SAMHSA published a report titled, Growing Older: Providing Integrated Care for an Aging population, which outlines various integrated care approaches available to clinicians treating older adults with mental health and substance use issues. The report stresses the importance of assessing elderly patients for cognitive deficits and adapting behavioral interventions to this population as needed (SAMHSA, 2016).
Clinical Features Commonly Associated with Hospital Admission
- The patient is psychotic
- The patient is impulsive
- The patient is severely agitated
- The patient has poor judgment
- The patient had lethal intent
- The attempt was premeditated
- Precaution was taken to avoid rescue or discovery
- The patient regrets surviving
Clinical Issues Surrounding Discharge: The Role of Follow-up
Suicide risk is highest in the 12 months following a hospital discharge, with one-third of the 12-month risk occurring in the first two weeks (Forte et al., 2019). These findings indicate the importance of immediate and sustained follow-up of patients post discharge.
Follow-up consists of a specific clinical program, such as returning to an outpatient provider (either new or ongoing), a step down program, or a residential treatment program. There is evidence that follow-up after initial contacts for suicidal ideation and after discharge from emergency departments and inpatient settings can save lives (Fleischmann, 2008; Gould et al., 2018; Motto & Bostrom, 2001; Vaiva et al., 2006; While et al., 2012).
Suggested Patient Discharge Information
- Provide the patient and, if relevant, the family/friends with discharge instructions
- Consider explaining the uneven recovery path from their illness, especially depression (e.g., “There are likely to be times when you feel worse—that doesn’t mean that the medications have stopped working. Contact your healthcare clinician if this happens”)
- Inform the family/friends (if indicated) about the signs of increased suicide risk; especially sleep disturbance, anxiety, agitation and suicidal expressions and behaviors
- Provide information for a follow-up appointment, which may include contacting current provider and/or scheduling an appointment
- If presence of firearms has been identified, document instructions given to patient and/or significant other
- Provide prescriptions that allow for a reasonable supply of medication to last until the first follow-up appointment (if indicated)
- Provide information about local resources available, including emergency contact numbers
Military and Veteran Populations
Veterans are 1.5 times more likely to die by suicide than non-veterans. Female veterans are particularly at risk, with a suicide rate 2.2 times higher than that of non-veteran adult women (Shane, 2019).
Other risk factors among military and veteran populations include early separation from service, recent deployment, lower rank, younger age, clinical depression, and comorbidity (Fazel & Runeson, 2020). For example, U.S. veterans with opioid use disorder have a rate of suicide six times greater than the general population. Having an opioid use disorder more than doubles the risk of suicide in female veterans, and increases the risk of suicide by 30% in male veterans (Oquendo & Volkow, 2018; opioidscreening.org).
Another risk factor among veterans and military personnel is access to lethal means. Over 60% of U.S. military suicides occur at home and involve a firearm (Pruitt et al., 2017). A recent study found that military personnel with suicidal ideation were 53% less likely to store firearms in a safe manner than those with no such history. In this same study, military personnel with recent thoughts of death or self-harm were 74% less likely to store their firearms safely (Bryan et al., 2019).
One of the DSM-5 changes that came out in 2013 is the use of the term “perinatal depression” as opposed to “postpartum depression.” The diagnosis of perinatal depression requires that the depression occurs during the pregnancy or during the first four weeks postpartum. The diagnostic criteria did not change in DSM-5, but the time period for relevant symptoms was extended (Stuart-Parrigon & Stuart, 2014). Perinatal depression also includes episodes that begin prior to pregnancy and persist during the pregnancy.
|Risk Factors for Suicidal Ideation in Pregnant Women|
While pregnant women are more likely than the general population to experience suicidal ideation, they are less likely than their non-pregnant counterparts to die by suicide (Gelaye et al., 2016). This finding holds both in the U.S. and abroad (Appleby, 1991; Gissler et al., 2005; Gelaye et al., 2016; Marzuk et al., 1997; Samandari et al., 2011). Nevertheless, suicidal ideation and attempts during pregnancy have been associated with adverse consequences, including low birth weight (Gelaye et al., 2016; Gandhi et al., 2016). In one study, infants born to mothers who reported depressive symptoms which included suicidal ideation weighed 240 grams less on average than infant born to mothers who reported depressive symptoms without suicidal ideation (Gelaye et al., 2016; Hodgkinson et al., 2010).
|Risk Factors for Suicide Completion in the Perinatal Period|
The suicide rate among women who have given birth in the last year is also significantly lower than the suicide rate among women who have not given birth. Nevertheless, suicide still occurs in postpartum women and, in fact, is one of the most common causes of maternal death in the year following delivery, accounting for about 20% of postpartum deaths (Lindahl, Pearson, & Colpe, 2005; Wisner et al., 2013). Women with a postpartum psychiatric hospitalization can be at greater risk for suicide during the first postpartum year than women without a postpartum psychiatric hospitalization (Appleby et al., 1998; Oates, 2003; Orsolini et al., 2016).
Postpartum Psychosis: Postpartum psychosis is relatively rare. It occurs in about 1 or 2 in 1000 deliveries (Luykx et al., 2019), compared to postpartum depression which occurs in 1 in 9 women (Ko et al., 2017).
- Suicidal or infanticidal thoughts
- Delusions or strange beliefs
- Feeling very irritated
- Decreased sleep
- Paranoia or suspiciousness
- Rapid mood swings
- Difficulty communicating at times
Women with this diagnosis often do not express their suicidal or infanticidal thoughts (Lukyx et al, 2019). On study has indicated that approximately 5% of women with postpartum psychosis ultimately die by suicide (Lucchesi, 2018). While suicide is uncommon during the immediate postpartum psychosis, it becomes more common during subsequent psychotic episodes and later in life (Brockington, 2017). Approximately one in three women who have experienced postpartum psychosis experience recurrence with subsequent pregnancies (Bergink et al., 2016). The most significant risk factors for postpartum psychosis are a previous psychotic episode and a personal or family history of bipolar disorder. There is an increased incidence of suicide among first-degree relatives of women with postpartum psychosis.
The rate of infanticide in women with a history of postpartum psychosis is approximately 4% (Lucchesi, 2018). Antipsychotics, lithium, and ECT can be effective for postpartum psychosis. Inpatient care is usually required (Bergink et al., 2016).
Perinatal Screening: There are variety of recommendations. Orsolini and colleagues (2016), for example, recommended that women be screened during the prenatal period – and particularly during pregnancy – for thoughts of self-harming and of harming infants, and asked about their own and their family mental health history. Mothers may need to be monitored and supported for a full year following their delivery.
The American Academy of Pediatrics (AAP) recommends that pediatricians screen mothers for depression at the baby’s one-, two-, and four-month visits. The AAP recommends using either the Edinburgh Postnatal Depression Scale (EPDS) or a two-question screen (Stuart-Parrigon & Stuart, 2014).
The risk of both first onset and recurrence of bipolar disorder is increased during the postpartum period. Nearly a quarter (22.6%) of postpartum women who screened positive for depression in one study had bipolar disorder (Wisner et al., 2013). A bipolar depression requires a different form of treatment than unipolar depression, including use of a mood-stabilizer or one of several second-generation antipsychotics (cariprazine, lurasidone, olanzapine+fluoxetine, quetiapine), with or without temporary use of an antidepressant, depending upon clinical response.
While many mothers may prefer not to use medication in perinatal period, there is now sufficient research support to suggest that, especially in the case of severe depression, it is more beneficial for both the mother and child for the depression to be treated. Many women need to take medication to achieve and maintain a euthymic mood during pregnancy and breastfeeding. Medication should not be discountinued without extensive discussion with prescribing physicians and/or other consultants.
Murder-suicide, also known as homicide-suicide, is when an individual kills one or more people before taking their own life. It is necessary for the two acts to occur in close proximity – in most cases, the suicide occurring within seconds or minutes of the homicide. Murder-suicides are very rare, with fewer than 1/year per 100,000 people occurring in the United States (Knoll, 2016). They account for only about one to two percent of all suicides (Jacobs, 1999).
Murder-suicides have been classified according to type and class. Type refers to the relationship between the perpetrator and victim. There are three types of murder-suicide: spousal/consortial, familial, and extrafamilial. Class refers to the principal motive or the precipitant for the murder-suicide. Some examples of classes are amorous jealousy, mercy killing, retaliation, and family financial or social stressors. Certain types of murder-suicides have been associated with certain classes. For example, spousal/consortial suicides are more likely to involve amorous jealousy, whereas familial suicides are more likely to be mercy killings because of the declining health of either the victim or the offender (Jacobs, 1999; Marzuk et al., 1992).
The majority of murder-suicides in the U.S. are perpetrated by men. Most cases involve a man killing a romantic partner or ex-romantic partner before killing himself. Common contributing factors are estrangement and history of domestic violence leading to impending divorce or separation. In the elderly, however, most murder-suicide cases involve an older male caregiver killing his ailing wife and then killing himself. Firearms are the most common method of homicide-suicide. Depression is common among perpetrators (Eliason, 2009).
The perpetrators of murder-suicide typically have a low rate of prior criminal behavior. This, along with the rarity of murder-suicide, makes prediction, impossible. As with attempts to predict simple suicide and homicide, any evaluation of murder-suicide is likely to overpredict mortality. Most individuals who fit the profile will never die in a murder-suicide event (Eliason, 2009; Jacobs, 1999).
Murder-suicide risk assessment is not very different from suicide risk assessment. Mental health clinicians should be alert for factors that may increase the risk of a tragic outcome, such as:
- History of domestic violence
- Access to lethal means, particularly a firearm
- Postpartum psychosis
- Suicide attempt, suicide plan, or suicidal ideation in context of interpersonal crisis
- History of financial stress in combination with severe relationship turmoil
- Obsessive or delusional jealousy, especially when comorbid with depression or paranoia
- Older males caring for a deteriorating partner
Interventions will include treating psychiatric symptoms, determining the need for hospitalization, removing access to firearms and other lethal methods, and connecting patients to psychosocial supports and other social services (APA, 2003).
Race, ethnicity, and culture
Suicide is sometimes erroneously thought of as only a “White man’s problem.” White males account for about 70% of all suicides in the United States. The suicide rate for White individuals in the U.S. is 18 per 100,000 persons compared to an overall suicide rate of 14.2 per 100,000. However, the suicide rate is actually highest in the American Indian/Alaskan Native population and is a significant problem in other racial and ethnic groups (SPRC, 2020). In addition, American Indian/Alaskan Native, Asian American, Black/African American, and Hispanic suicides are often undercounted, either due to medical examiners misclassifying the deaths or families not wanting to report the suicide due to stigma (Dennis, 2018).
American Indian/Alaskan Native Populations: American Indian and Alaskan Native (AI/AN) populations have the highest suicide rate of all racial and ethnic groups in the U.S., with 22.1 suicides per 100,000 persons in 2018. While suicide rates in the overall U.S. population are highest among middle-aged adults, suicide rates in AI/AN populations are highest among adolescents and young adults (SPRC, 2020).
There is significant cultural and ethnic heterogeneity among AI/AN populations. There are currently 574 federally recognized tribal nations and Alaska native villages, with members speaking over 200 languages (National Congress of American Indians, 2020). AI/AN have the highest poverty rate of any racial and ethnic group in the U.S. While the rate of mental disorders, and especially those associated with suicide, are high in this population, mental health treatment rates are low (APA, 2020). Reasons may include a lack of available services, lack of culturally competent care, economic barriers, and stigma (SAMHSA, 2010).
Potential risk factors for suicide in the AI/AN population include higher rates of alcohol use disorder, substance use disorder, and posttraumatic stress disorder, as well as stressors related to poverty discrimination, racism, and historical trauma (SAMHSA, 2010). SAMHSA has published a wonderful guide for understanding suicide within AI/AN communities and promoting culturally sensitive practices in these communities. To access this manual, click here.
Asian American and Pacific Islander Populations: The Asian American and Pacific Islander (AA/PI) population in the U.S. is very diverse, consisting of approximately 50 subpopulations and over 100 languages. Studies have found that only 30% of this population is fluent in English, presenting a significant barrier to accessing mental health services (APA, 2020).
Other obstacles to accessing mental health care include stigma, especially among first-generation immigrants. In AA/PI cultures, having a mental illness can be a source of shame and weakness. Structural barriers also exist, including lack of cultural competency among service providers and a lack of research specific to these populations. These factors may contribute to the finding that the AA/PI population is the least likely of all racial and ethnic groups in the U.S. to seek mental health care (APA, 2020).
With respect to suicide, the suicide rate among AA/PI populations is highest among the elderly and the young, in contrast to the overall U.S. population, where suicide peaks in middle-aged adults. The suicide rate among AA/PI young adults has also been on the rise, according to recent CDC data (SPRC, 2020; SAMHSA, 2018).
The World Health Organization and Each Mind Matters: California’s Mental Health Movement have highlighted educational resources and outreach materials about suicide in Bengali, Chinese, Hmong, Khmer, Korean, Lao, Mien, Tagalog, Vietnamese, and Japanese, which you can share with your patients.
Black/African American Populations: Black/African American communities make up about 13% of the U.S. population. Only one-third of Black/African American individuals who are in need of mental health care receive it. They are less likely to be offered evidence-based medicines, psychotherapy, and other outpatient services compared to the general population. Black/African American individuals with psychotic disorders (e.g., schizophrenia, bipolar disorder) are also more likely to be incarcerated than those with these conditions in other racial and ethnic groups (APA, 2020). In addition to stigma and structural racism, other barriers to treatment in Black/African American communities include lack of culturally-competent care, lack of insurance, and lack of trust in the healthcare system (APA, 2020).
Over the past few decades, suicide attempts among Black/African American adolescents have increased significantly (Lindsey et al., 2019). Black/African American high school youth are more likely than the overall high school youth population to have attempted suicide in the past year and their suicide attempts are more lethal (SPRC, 2020).
Recently, the Office for Disparities Research and Workforce Diversity at the National Institute of Mental Health hosted a webinar with experts in the field entitled Responding to the Alarm: Addressing Black Youth Suicide. The video and transcript can be accessed here.
Hispanic and Latino Populations: The U.S. Hispanic/Latino population is also very diverse, and includes people from throughout Latin America and other Spanish-speaking countries. Research on suicide in the Hispanic population is limited, but suggests that mental health treatment in this population is low. In 2018, Hispanic adults were half as likely to receive mental health treatment as non-Hispanic White adults. Barriers to treatment in this population include a shortage of bilingual or Spanish-speaking mental health professionals, low rates of insurance coverage, and stigma surrounding mental illness (APA, 2020).
In 2017, suicide was the second leading cause of death for Hispanics aged 15 to 34. CDC data show that Hispanic adolescents have high rates of suicide attempts, especially girls. Suicide attempts for Hispanic girls, grades 9-12, were 40 percent higher than for non-Hispanic White girls in the same age group, in 2017 (CDC, 2019; HHS, Office of Minority Health).
Resources for Providers
Lack of cultural understanding by health care providers may contribute to treatment disparities in racial and ethnically diverse groups. The American Psychiatric Association’s Cultural Competency webpage has a wealth of information about working with diverse populations. To access this webpage, click here.
Health Care Providers
Physicians should also be alert for signs of suicidal risk in themselves and in their colleagues, not just in their patients. The rate of suicide among physicians is 28-40/year per 100,000, which is 2-4 times the rate in the general population. In fact, according to a recent presentation at an American Psychiatric Association conference, physicians were reported to have the highest rate of suicide of any profession. The rate of suicide among physicians is even higher than among military personnel. The rate is also high among other health care professionals, including nurses, dentists, and veterinarians (Hawton et al., 2011; Tomasi et al., 2019).
Although depression appears to afflict physicians at rates similar to that of the general population, the suicide rate is significantly higher in physicians, and especially among women. Unlike the gender gap in the general population, female physicians have a completion rate approximately equal to that of their male colleagues. Having knowledge of and access to lethal substances may account for the higher rate of suicide completion among doctors.
Medical students and physicians experience significant stress, including high demands, competitiveness, long hours, and lack of sleep. These may contribute to alcohol and substance abuse, which are risk factors for suicide. Between 10% and 15% of physicians report alcohol or substance abuse compared with 9% of the general population (Baldisseri, 2007).
Stigma is an obstacle to seeking treatment. In one study of 954 medical students who screened positive for depression, only 15% sought psychiatric treatment (Hoffman & Kunzmann, 2018; Rotenstein et al., 2016). Half of women physicians completing a Facebook questionnaire reported meeting criteria for a mental disorder, but said that they were reluctant to seek professional help because of the fear of stigma (Gold, 2016).
The American Foundation for Suicide Prevention has a collection of resources for physicians who may be dealing with professional burnout, depression, and suicidal feelings, which can be accessed here.
The current Covid-19 pandemic is presenting additional mental health challenges to health care workers, including suicide. Click here to read a recent opinion piece on the topic, which contains suggestions for how you might be able to mitigate suicide risk among your medical colleagues.