Suicide is a major public health problem not only in the United States but many western nations. In the United States, it is the 10th leading cause of death, accounting for nearly 44,000 deaths each year, more than double the deaths due to AIDS. Suicide is also the seventh leading cause of years of potential loss of life, surpassing liver disease, diabetes, and HIV. Each year, nearly half a million individuals present to the emergency rooms in the United States following attempted suicide. Data indicate that nearly 1 out of every 7 young adults describe as having some type of suicidal ideation at some point in their lives and at least 5% have made a suicidal attempt. Suicide has repercussions way beyond the affected individual. It costs the US healthcare system over $70 billion, and untold billions of dollars are lost by the families who are affected, in terms of loss of earning.
Suicides are at an all-time high and affect both genders. Men are nearly 3.5 times more likely than women to commit suicide, and on average 123 people kill themselves every day.
The World Health Organization (WHO) has predicted that in the next 2 years, depression will the leading cause of disability globally. Depression is not only a North American phenomenon but is now being diagnosed in almost every nation. The annual prevalence of major depressive disorders in North America is 4.5%, but this is a gross underestimate because many individuals do not seek medical help. Depression is a serious medical disorder and associated with a high risk of suicide. Data reveal that more than 90% of individuals with a major depressive disorder do see a healthcare provider within the first 12 months of the episode and at least 45% of suicide victims have had some contact with a primary health care provider within the 4 weeks of suicide. This indicates that perhaps, if there healthcare providers are more vigilant and alert, suicide could be prevented in these individuals.
These grim statistics have led to a National Strategy for Suicide Prevention in the United States.
Considering that many individuals who commit suicide have a mental health disorder and have visited their primary caregiver, the focus now is on health care providers to become aware of the factors that increase the risk of suicide and to refer these individuals to mental health professionals for some type of intervention. The current USPSTF recommendations are that primary caregiver's screen adolescents and adults for depression only when there are appropriate systems in place to ensure adequate diagnosis, treatment, and follow-up.
Many factors have been identified in individuals who commit suicides or have attempted suicide. These factors include the following:
Over the years several other risk factors even identified with an increase the risk of suicide, and they include:
The most important thing to understand is that having just one risk factor has very limited predictive value. Millions of Americans have one of these factors at any one point in time, but very few attempt suicide and even fewer die as a result. One has to look at the entire clinical picture to increase the predictive values of these risk factors.
Which type of mental health disorder is associated with an increased risk of suicide?
Accumulated data reveal that many types of mental health disorders have been associated with an increased risk of suicide and they include the following:
Medications and Suicides
Several medications have been linked to suicidal behavior, and this has promoted the FDA to require a black box warning on several prescription medications which include analgesics, anticonvulsants, and antidepressants.
The risk of suicide varies by gender, age, ethnicity, or race. Suicide is known to occur in people of all ages, including high school students, but the highest rate of suicides are known to occur in seniors older than age 75.
Professions associated with a high rate of suicide include law enforcement and public safety officers (physicians, firefighters). These professionals often work long irregular hours, witness all types of injuries, have exposure to guns or potent drugs, which places them at high risk for suicide. Many of these professionals use alcohol and often the trigger is a divorce. Physicians have a particularly high rate of divorce because of job-related stress and the reluctance to seek help.
One study revealed that medical residents frequently have a high rate of suicidal ideations but often do not seek help. Over the past 3 decades. suicides among the military personnel have also been steadily increasing.
Seasonal Variances in Suicide
Suicides also tend to have a seasonal occurrence with the majority occurring during spring. The month of May is particularly notorious for having the most suicides. The general belief is that the long winter usually dampens the moods, and with the arrival of spring, some depressed people who remain depressed end their life.
Despite the belief that year-end holidays are a frequent period of suicide, data do not support that notion. Studies show that end of year holidays are usually associated with the lowest rates of suicides.
Relationship Between Suicides and Birthdays
Some people do commit suicide on their birthday. These individuals are usually males between ages 25 to 54, and irrespective of a mental health history are known to commit suicide on their birthday. These suicides usually cannot be prevented as most males do not show up at the doctor’s office on their birthday.
Suicide in Pregnancy
Even though postpartum depression is commonly reported in women, the actual rates of suicide are rare. Suicide during the pregnancy is even rarer. In any case, pregnant and postpartum females should be screened for depression.
Ways of Committing Suicide
Suicide is committed in many ways, but firearms account for nearly 51% of cases. Other causes include the use of medications, jumping off buildings, hanging, jumping in front of the train, or drowning. In the United States, close to 50% of all suicides are completed with a gun. About 56% of men kill themselves with a gun, whereas only 30% of females use a gun for suicide. Other means of suicide in the United States include suffocation and poisoning.
Availability of Firearms
In the United States, the most common method of committing suicide is with the use of firearms. Men are many more times likely to use a firearm compared to women. Further, the risk of suicide with a firearm in men increases when the depressed individual also uses alcohol. Hence, when evaluating these individuals for suicide risk, one should determine if they own a firearm. All healthcare workers should be aware of the state statutes on possession of firearms and mental illness. Many states ban the possession of firearms by individuals with mental illness, but recent shootings in the Unite States indicate that many mentally ill patients continue to have access to firearms.
Screening for Suicide
There has been a lot of debate on the use of universal screening for depression in primary care. However, the universal feeling is that such screening should only be undertaken if there is a strong commitment to provide treatment and follow up. There are many screening tools for suicide, and there is no one screening tool that is applicable in all patients with risk for suicide. In addition, one should not always rely on the screening tool but also get to know the patient and the past mental health history.
Targeted Screening versus Universal Screening
Many countries including Canada, Australia, the United Kingdom, and several other European countries have concluded that there is moderate evidence to recommend screening for depression in the primary care setting. The little evidence collected reveals that screening does improve health outcomes when it is associated with close follow up and treatment. However, screening alone without any follow up is not recommended as there is inadequate evidence that it helps prevent or reduce the risk of suicide. Instead of universal screening, some experts have suggested targeted screening as is done in Wales and England. For targeted screening, the following population has been identified as a risk for suicide:
Available Screening Tools
The Beck Fast scan is recommended by the USPSTF. It has seven long questions that can help determine the intensity and severity of the depression.
Suicide risk screen is a 10-item questionnaire that is often used to screen for suicide, especially in young people.
The Patient Health Questionnaire (PHQ) can also be used to identify high-risk patients. It consists of 9 items that ask various questions about self-harm.
The SAFE-T: The SAFE-T tool can be used in an outpatient setting and does offer a good insight into the extent and nature of suicidal thoughts and harmful behavior. The SAFE-T explores the following:
C-SSRS: The Columbia-Suicide Severity Rating Scale (C-SSRS) is another tool that can be utilized in outpatient settings to assess for the presence of harmful behavior. The C-SSRS also assess any known suicide attempts and also assesses the suicide ideations and behaviors. Like the SAFE-T it can be used as an initial screen.
Cautions Regarding Screening
The sensitivity and specificity of the currently available screenings tool vary from 50% to 100% and 60% to 98%. No one instrument is 100% sensitive, and choosing one depends on personal preference and experience. When initiating a screening program for suicide, it is important to have the existence of and access for effective treatment and follow up. Other considerations include:
Because not all patients complete or refuse the initial screen, the healthcare providers must be persistent in the use of these screening tools. Countless reports indicate that follow up on these patients has been universally poor. Hence, the primary care provider must ensure that patient identified with major depression is followed up. In many cases, after the initial screen is completed and support provided, patients are never rescreened again for depression. Because depression has no cure and relapse is common, rescreening should be continued at regular intervals.
The one negative about going to primary care providers for depression or any mental health disorder is that these professionals simply do not have time. They often have many other patients to deal with and can barely spare more than 15 minutes at each visit. Patients with psychosocial or emotional problems usually require much longer visits and if they feel hurried, will not show up again.
All healthcare workers who screen for suicide should be aware that the screening tools can lead to a false positive, which in turn can lead to high costs of medical care for the individual. This can be of severe burden, for patients who do not have private insurance. A Canadian study revealed that many individuals who are suicidal have no symptoms or signs of depression. These people are very unlikely to seek assistance for healthcare providers, compared to people who are depressed.
The Patient History
It is important to obtain a thorough patient history especially about thoughts and self-destructive behavior. Even though many individuals talk about suicide, they rarely follow through with it, but the opposite is true. It is established that a threat of suicide can be followed with a completed act and the presence of suicidal ideation is closely associated with suicidal behavior.
What are Signs Suggestive of an Impending Suicide?
Over the years, experts have compiled a list of signs that may be indicative of an impending suicide, and they include the following:
What Activities are Associated with an Intent to Commit Suicide?
Several activities that have been associated with an intent to commit suicide include the following:
From an analysis of past suicide cases, it appears that a number of individuals go to the emergency room or visit their primary health care provider a few weeks prior to committing suicide. At this visit, they rarely mention suicidal directions but may have vague physical complaints. Thus, the healthcare provider must try and obtain a good mental health history beyond just the chief complaint.
Factors That May Protect Against Suicide
The healthcare worker should also try to ascertain protective factors against suicide such as:
Mental Status Assessment
In some cases, assessment of the mental status may provide a clue to the individual’s potential for self-harm.
It is vital that the healthcare professional not only rely on the screening tools to identify patients at risk for suicide. It is important to conduct a patient interview at the same time to reflect the following:
Once the patient is deemed to be at risk for suicide, then intervention steps must be initiated right away. The following steps must be instituted right away:
If the patient is sent home, then the following additional safety measures must be established:
Once the individual is safe as an inpatient or outpatient, a formal treatment plan should be established. The next step is to refer all patients deemed to be at higher risk for suicide to a mental health counselor as soon as possible. Every state has laws and procedures regarding this process which must be incorporated into the clinical practice when addressing individuals at high suicide risk.
If the individual has acute psychiatric symptoms like paranoia, hallucinations, extreme anxiety or depression, pharmacological therapy may be needed. After the patient’s acute symptoms have been managed, the choice of further treatment depends on the specific mental illness. In most cases, psychotherapy is recommended to remove the thoughts about self-harm. However, it is important to note that despite these interventions, many patients do commit suicide. Hence it is important to involve the patient’s family, friends and social worker in the long-term management of these patients.
While drug treatment is useful for management of acute symptoms like hallucinations, psychosis or depression, psychotherapy is essential for long-term management. Cognitive behavior therapy and other related therapies like problem-solving therapy, dialectical behavior therapy, and developmental group therapy have all been used to lower the risk of suicide. A psychiatrist or psychotherapist usually administer these treatments. The problem is that these therapies require regular sessions spread over many months or even years. The other problem is the cost which can be high for those not covered by medical insurance.
Moving Beyond Screening
Some experts suggest an alternative approach to preventing suicide other than identifying individuals at risk. The reason is that the present medical model of screening has not been shown to be effective in suicide prevention. Suicide has been strongly linked to social problems, and the rates are generally much higher in local communities which lack a cohesive social fabric or when individuals are left out of mainstream society. Thus, the social factors should be targeted like improving housing, providing opportunities for job, making it easy to access mental health care professionals and prescription medications. Unfortunately, many of the social factors go way beyond the ability of most primary health care providers to manage. Plus, there is also a significant cost that comes with making changes in social structure.
What is an Effective Follow-up?
Experts say that if a screening program for suicide prevention and depression is to be started, then there must be effective follow-up and treatment. Once an individual has been diagnosed with depression and is at high risk for suicide, then there must be a system in place for treatments such psychotherapy and/or antidepressant medications. If close follow up and treatment is not available, then the clinician has the onus of recommending a referral and following up.
Is There Evidence that Screening for Suicide Can Improve Outcomes?
Evidence shows that when the screening tools are used appropriately, there can be useful in helping healthcare workers recognize depression. When the screening tools are accompanied by a commitment to follow up and treatment, better outcomes are achieved. However, screening tools are only to be used by healthcare workers who are committed to using the information from the screening test and to provide enhanced care. The current evidence on screening for suicide risk in primary care is insufficient, and the balance of benefits and harms of screening cannot be determined.
At the moment there is little evidence to support screening the population at large. In fact, in people without any psychiatric history, the role of screening remains debatable. Thus, healthcare workers are being urged to first identify patients with risk factors for suicide and those with high levels of mental stress and refer them for further evaluation. So far, each hospital or organization has its protocols when it comes to the use of suicide prevention tools. No study has ever shown that one tool is better than the other.
Can Screening for a Suicide Lead to Harm?
To date there is insufficient to determine for screening for suicide leads to harm to the individual or society as a whole. Presently, the USPSTF has concluded that the evidence for suicide screening in primary care is inadequate and that the balance between harm or benefit cannot be determined.
The costs of screening for suicide are minimal. Except for some time and the use of questionnaires, there are no other exorbitant costs. The latest data reveals that less than 20% of primary care physicians screen adolescents or seniors for suicidal risk factors.
Screening for Suicide Risk Summary of the Recommendations
Adolescents, adults, and older individuals who do not have an identified psychiatric disorder do not need a screen. The indication to screen depends on the presenting and past clinical history.
Since the suicide risk varies by gender, age, and race/ethnicity, some populations need careful screening, for example, older white males.
Assess for presence of:
In men assess for socioeconomic factors, such as low income, occupation, and unemployment.
In older adults, additional risk factors, such as social isolation, spousal bereavement, neurosis, affective disorders, physical illness, and functional impairment.
Risk factors of importance to military veterans include traumatic brain injury, separation from service within 12 months, posttraumatic stress disorder, and mental health conditions.
It is important to understand that one single risk factor has very little predictive value and hence, one should look at the entire picture. Many Americans have one risk factor for suicide at any point in their life, but very few will attempt suicide, and even fewer will die from it.
The choice of screen test is a matter of personal preference because they all have a broad range of accuracy. Data on predictive values of the screening tests are limited.
Once a patient is deemed to be at risk for self-harm, referral to a mental health professional is recommended. The key treatment to reduce the risk of suicide is psychotherapy, which includes cognitive behavior therapy (e.g., dialectical behavior therapy, problem-solving therapy, and developmental group therapy).
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