Suicide Risk Assessment
What is Suicide?
“The termination of an individual’s life resulting directly or indirectly from a positive or negative act of the victim himself which he knows will produce this fatal result” –Emile Durkheim, 1857 (French Sociologist)
Suicide is death caused by injuring oneself with the intent to die. The term “suicide” implies any level of intent. A suicide attempt occurs when someone harms themselves with the intent to die, but they do not die.
♦ Terms used to describe a suicidal act in which there was any level of intentto end their life:
- Completed suicide: Death from injury, poisoning, or suffocation where there is evidence that the injury was self-inflicted and that the person intended to kill themselves
- Suicide attempt with injuries: An action resulting in a nonfatal injury where there is evidence that the injury was self-inflicted and that the person intended to kill themselves.
- Suicide attempt: A potentially self-injurious behavior with a nonfatal outcome where there is evidence that the person intended to kill themselves.
- Suicidal Act: A potentially self-injurious behavior that may result in death (completed suicide), injuries, or no injuries AND there is evidence that the person intended to kill themselves.
- Aborted suicide attempt: A potentially self-injurious behavior with evidence (either explicit or implicit) that the person intended to die but stopped the attempt before physical damage occurred.
- Suicidal Ideation: Thoughts of serving as the agent of one’s own death.
♦ Terms used to describe suicide-related behaviors in which there was NO intent to end their life:*
- Para-suicidal acts
- Suicidal gestures
- Self-injurious behaviors
- Manipulative acts
- Reactive acts
*Usually, the person wishes to use the appearance of intending to kill themselves in order to attain something.
Reference: O’Carroll PW, Berman AL, Maris DW, et al: Beyond the Tower of Babel: a nomenclature for suicidology. Suicide & Life Threatening Behavior 1996; 26 (3): 237-252
How to assess intent:
(1) Does/Did the patient understand/know the lethality of the method used?
Consider the following scenarios of two separate patients who took an overdose of ten (10) ibuprofen tablets:
Patient A: A 20 year old female with Autism who was told multiple times in the past that taking too much ibuprofen would kill her.
Patient B: A 20 year old female college student knew ten (10) ibuprofen tablets would not kill her.
Despite ingesting only 10 ibuprofen tablets, Patient A was intending to kill herself.
(2) Did the patient use a method with high lethality?
Pulling the trigger of a firearm suggests a higher level of intent than ingesting 10 ibuprofen tablets.
(3) Was the attempt planned and organized with active measures to prevent discovery or intervention?
Consider the following scenarios of two separate patients who ingested a lethal amount of opioids:
Patient A: A 20 year old male who took a cab to a hotel, left his phone in his room, and waited until others weren’t around to take an overdose.
Patient B: A 20 year old male who took an overdose in the living room of his family home when his parents were expected home shortly.
Patient A was clearly intending to kill himself.
(4) Was the patient persistent?
A patient who took an overdose of sleeping medication then woke up and took another overdose and then woke up again and drove to the store to buy more and took more is a patient who was clearly persistent with higher level of intent.
SUICIDE RISK ASSESSMENT
Statistically speaking, suicide is very rare, even in populations at high risk. The vast majority of individuals with suicidal thoughts will never attempt or complete suicide. But when it does happen, it is devastating. Contrary to popular belief, psychiatrists are not experts at predicting suicide. Instead, psychiatrists identify specific factors that may increase or decrease risk for suicide and suicidal behaviors and try to modify those risk factors that are modifiable. When patients are considered at very high risk, the goal is to successfully treat the underlying disease and/or accurately identify periods of imminent suicide in order to intervene. Part of the intervention is determining which setting is most appropriate for the patient given their level of risk.
♦ Non-Modifiable Risk Factors for Suicide
- Gender: Males are at higher risk than females
- Race: White/Caucasian higher risk than Non white minority
- Age: Older individuals are at higher risk than younger individuals
- Previous suicide attempts (GREATEST PREDICTOR OF FUTURE SUICIDE)
- Family history of suicide
♦ Modifiable Risk Factors for Suicide
- Current suicidal ideation
- Access to high lethality means (firearms at home)
- Recent loss (job, divorce, investment, money, relationship)
♦ Factors Associated with an Increased Risk for Suicide:
- Suicidal ideas (current or previous)
- Suicidal plans (current or previous)
- Suicide attempts (including aborted or interrupted attempts)
- Lethality of suicidal plans or attempts
- Suicidal intent
- Major depressive disorder
- Bipolar disorder (primarily in depressive or mixed episodes)
- Anorexia nervosa
- Alcohol use disorder
- Other substance use disorders
- Cluster B personality disorders (particularly borderline personality disorder)
- Comorbidity of axis I and/or axis II disorders
- Diseases of the nervous system
- Multiple sclerosis
- Huntington’s disease
- Brain and spinal cord injury
- Seizure disorders
- Malignant neoplasms
- Peptic ulcer disease
- Chronic obstructive pulmonary disease, especially in men
- Chronic hemodialysis-treated renal failure
- Systemic lupus erythematosus
- Pain syndromes
- Functional impairment
- Recent lack of social support (including living alone)
- Drop in socioeconomic status
- Poor relationship with family
- Domestic partner violence
- Recent stressful life event
- Childhood traumas (sexual/physical abuse)
- Family history of suicide (particularly in first-degree relatives)
- Family history of mental illness, including substance use disorders
- Psychic pain
- Severe or unremitting anxiety
- Panic attacks
- Shame or humiliation
- Psychological turmoil
- Decreased self-esteem
- Extreme narcissistic vulnerability
- Aggression, including violence against others
- Loss of executive function
- Thought constriction (tunnel vision)
- Polarized thinking
- Male gender
- Widowed, divorced, or single marital status, particularly for men
- Elderly age group (age group with greatest proportionate risk for suicide)
- Adolescent and young adult age groups (age groups with highest numbers of suicides)
- White race
- Gay, lesbian, or bisexual orientation
- Access to firearms
- Substance intoxication (in the absence of a formal substance use disorder diagnosis)
- Unstable or poor therapeutic relationship
♦ Factors Associated with Protective Effects for Suicide:
- Children in the home (except in postpartum psychosis or mood disorders)
- Sense of responsibility to family
- Pregnancy (except in postpartum psychosis or mood disorders)
- Life satisfaction
- Reality testing ability
- Positive coping skills
- Positive problem-solving skills
- Positive social support
- Positive therapeutic relationship
♦ American Psychiatric Association Guidelines, 2010
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
- Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
- Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
- Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 6th edition.