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Suicide and Suicidal Behaviors. Scott Stroup, M.D., M.P.H. 2004. Definitions. Suicide : intentional self-inflicted death Suicidal ideation : thoughts of killing oneself (i.e., serving as the agent of one’s death)

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suicide and suicidal behaviors

Suicide and Suicidal Behaviors

Scott Stroup, M.D., M.P.H.


  • Suicide: intentional self-inflicted death
  • Suicidal ideation: thoughts of killing oneself (i.e., serving as the agent of one’s death)
  • Suicidal act: intentional self-injury (can have varying degrees of lethal intent)
  • Suicidal behaviors are the most common psychiatric emergency
  • The 11th leading cause of death in U.S. (2001)
  • About 30,000 suicides annually in U.S.
  • Over 90% of suicide victims have a diagnosable psychiatric disorder—over half have a depressive disorder
attempts vs completions
Attempts vs. Completions
  • Ratio of attempts to completions may be as high as 25:1
  • Women more likely to attempt suicide
  • Men more likely to complete suicide
  • Men use more lethal means
psychopathology is the primary underlying risk factor
Psychopathology isthe primary underlying risk factor
  • Major depression
  • Bipolar disorder
  • Schizophrenia
  • Substance use disorders
  • Personality disorders: borderline, antisocial
  • Panic disorder
highly important underlying risk factors
Highly important underlying risk factors
  • History of previous attempts
  • Depression
  • Alcohol or drug abuse
other underlying risk factors
Other underlying risk factors
  • History of psychiatric hospitalization
  • Chronic medical illness
  • Family history of suicide
  • History of childhood abuse (physical, verbal, or sexual)
  • Impulsiveness
underlying sociodemographic risk factors
Underlying sociodemographic risk factors
  • Social isolation:-Living alone-Not currently married (never married, separated, divorced, or widowed)
  • Unemployment
  • Male gender
  • Increased age (among white men)
  • Certain occupations: police officers, physicians
biologic factors
Biologic Factors
  • Serotonin abnormalities
    • decreased CSF 5-HIAA
    • increased 5-HT2A receptors
    • linked with impulsivity and aggression
    • PET: abnormal metabolism in prefrontal cortex
  • Genetics
    • familial association beyond risk for specific diagnoses
proximal risk factors
Proximal Risk Factors
  • Intoxication
  • Stressful life events:-loss of job-death of a loved one-divorce-migration-incarceration
suicide contagion there is some evidence this phenomenon exists
Suicide Contagion—there is some evidence this phenomenon exists
  • Direct or indirect exposure to suicide or suicidal behaviors can result in an increase in these behaviors, especially in adolescents and young adults
  • Because of reports of contagion resulting from media reports, recommendations to media include:

-reports should be factual, concise, non-repetitive

-reports should avoid oversimplified explanations of cause

-detailed descriptions of method should not be provided

-reports should not glorify victim or imply that suicide was effective in helping the person to attain some goal

-reports should provide information on how to get help

firearms greatly increase the risk of completed suicide
Firearms greatly increase the risk of completed suicide
  • Presence of a gun in the home increases risk of suicide 5X
  • Readily accessible firearms facilitate lethal impulsive acts and leave little chance for rescue
  • 70-90% fatality rate for suicidal firearm injuries
  • Women’s use of firearms has risen dramatically—now firearms are leading method of completed suicide by women in U.S.
most common methods of completed suicide

Firearms (61%)



Firearms (37%)


Most common methods of completed suicide
psychological factors theories
Psychological factors/theories
  • Hopelessness, despair, desperation
  • Freud: aggression turned inward
  • Escape from rage
  • Guilt; self-punishment or atonement
  • Rebirth or reunion fantasies
  • Control over a relationship
  • Revenge
religion and suicide
Religion and Suicide
  • Lower rates among Jews and Catholics, presumably due to religious prohibition
  • Lower rates in predominately Catholic countries, but this is not consistent
  • Religious affiliation is apparently less important than religious involvement and participation in affecting risk of suicide
china a different pattern of suicide
China—a different pattern of suicide
  • Rate is twice that of the U.S. (23/100,000)
  • 5th leading cause of death
  • Relatively more completed suicides by women (more than men)
  • Mental disorders less prevalent among suicide victims
  • Rural rate is 3X urban rate--many suicides among female peasants who impulsively drink lethal pesticides
  • Suicide not as strongly stigmatized as in West
suicide and schizophrenia i
Suicide and Schizophrenia (I)
  • 33-50% with schizophrenia will attempt suicide
  • Approximately 10% with schizophrenia die by suicide
  • Gender: equal attempt ratio, more men die by suicide
  • Isolation (single, living alone, unemployed)
  • Substance abuse
  • Akathisia
suicide and schizophrenia ii
Suicide and Schizophrenia (II)
  • Periods of increased risk:
    • Highest risk in first 10 years of illness
    • When depression
    • When hopeless
    • After resolution of an acute psychotic exacerbation
    • Days, weeks, months after hospitalization
  • Persons with more “insight” thought to be at higher risk of suicide
suicide among physicians
Suicide among physicians
  • Rate higher than general population, particularly for women doctors (same rate in male, female MDs)
  • Unrecognized and untreated depression a common theme
  • Physician help-seeking highly suboptimal:
    • 1/3 of physicians have no regular doctor
    • Low rates of seeking help for depression
    • Professional attitudes discourage admission of health vulnerabilities
    • Concerns about confidentiality, licensing, privileges, medical insurance, malpractice insurance
    • When seek help often quite ill

Figure. Proportionate Mortality Ratio for White, Male Physicians vs. White, Male Professionals, 1984-1995

Center et al, JAMA, June 18, 2003


Box. Profile of a Physician at High Risk for Suicide

Sex:Male or female

Age: 45 Years or older (woman); 50 years orolder (man)

Race: White

Marital status: Divorced, separated,single, or currently having marital disruption

Risk factors:Depression, alcohol or other drug abuse, workaholic, excessiverisk taking (especially high-stakes gambler, thrill seeker)

Medicalstatus: Psychiatric symptoms or history (especially depression,anxiety), physical symptoms (chronic pain, chronic debilitatingillness)

Professional: Change in status—threats to status,autonomy, security, financial stability, recent losses, increasedwork demands

Access to means: Access to legal medications,access to firearms

Center et al, JAMA, June 18, 2003

assessment of suicidality
Assessment of suicidality
  • Ask about suicidality in every initial psychiatric assessment
  • Asking about suicidality does not suggest it
  • Do not dismiss someone’s suicidal comments
  • Spectrum of suicidality: passive thoughts, plan, intent, attempt
  • Intent is not always communicated
  • No absolute predictive test or criteria
when assessing suicide risk consider
When assessing suicide risk, consider:
  • Pervasiveness of thoughts
  • Plan
  • Lethality of plan/attempt
  • Availability of lethal means
  • Likelihood of rescue
markers of increased suicide risk
Markers of increased suicide risk
  • Preparations for death: Settling affairs, giving away personal items, writing a note
  • Sudden change of mood
  • Lack of future plans
  • Recent loss
  • Symptoms: Insomnia, hopelessness, severe anxiety, extreme restlessness or agitation
management of suicidal patients
Management of suicidal patients
  • Determine treatment setting: Inpatient or outpatient
  • Caution regarding “contracts for safety”
  • Medications
  • Limit availability of firearms, lethal drugs, other means
  • Access to crisis services needed
  • Therapy
regarding risk factors for suicide
Regarding risk factors for suicide
  • Risk factors alone or in combination do not allow accurate prediction of a specific individual’s suicide
  • However, knowledgeable assessment of risk and protective factors can allow estimation of an individual’s risk and can be used to formulate a plan to reduce the risk of suicide
what every doctor should know about suicide
What every doctor should know about suicide
  • Depression is the most common diagnosis associated with suicide: recognize it, treat or refer
  • Do not ignore suicidal comments, threats
  • Asking about suicide does not suggest it
  • The 3 most important risk factors: history of suicide attempts, depression, substance abuse