Emergency Psychiatric Medicine
30.1 Suicide
Suicide is derived from the Latin word for “self-murder.” It is a fatal act that represents the person’s wish to die. There is a range, however, between thinking about suicide and acting it out. Some persons have ideas of suicide that they will never act on; some plan for days, weeks, or even years before acting; and others take their lives seemingly on impulse, without premeditation. Lost in the definition are intentional misclassifications of the cause of death, accidents of undetermined cause, and so-called chronic suicides—for example, death through alcohol and other substance abuse and consciously poor adherence to medical regimens for addiction, obesity, and hypertension.
EPIDEMIOLOGY
Approximately 30,000 deaths are attributed to suicide each year in the United States. This is in contrast to approximately 20,000 deaths annually from homicide. Although significant shifts were seen in the suicide death rates for certain subpopulations during the last century (e.g., increased adolescent and decreased elderly rates), the rate has remained fairly constant, averaging about 12.5 per 100,000 through the 20th century and into the 21st. Whereas the overall suicide rate has remained relatively stable, however, the rate for those 15 to 24 years of age has increased two- to threefold. Suicide is now the eighth-leading overall cause of death in the United States, after heart disease, cancer, cerebrovascular disease, chronic obstructive pulmonary disease, accidents, pneumonia and influenza, and diabetes mellitus.
Suicide rates in the United States are at the midpoint of the rates for industrialized countries as reported to the United Nations. Internationally, suicide rates range from highs of more than 25 per 100,000 persons in Scandinavia, Switzerland, Germany, Austria, the eastern European countries (the so-called suicide belt), and Japan, to fewer than 10 per 100,000 in Spain, Italy, Ireland, Egypt, and the Netherlands.
A state-by-state analysis of suicides in the last decade among persons between the ages of 15 and 44 years revealed that New Jersey had the nation’s lowest suicide rates for both sexes. Nevada and New Mexico had the highest rates for men, and Nevada and Wyoming had the highest rates for women. Women in Nevada killed themselves at a higher frequency than did men in New Jersey. The prime suicide site of the world is the Golden Gate Bridge in San Francisco, with more than 800 suicides committed there since the bridge opened in 1937.
Risk Factors
Gender Differences.
Men commit suicide more than four times as often as women, a rate that is stable over all ages. Women, however, are four times more likely to attempt suicide than men. Men’s higher rate of completed suicide is related to the methods they use: firearms, hanging, or jumping from high places. Women more commonly take an overdose of psychoactive substances or a poison, but their use of firearms is increasing. In states with gun control laws, the use of firearms has decreased as a method of suicide. Globally, the most common method of suicide is hanging.
Age.
Suicide rates increase with age and underscore the significance of the midlife crisis. Among men, suicides peak after age 45 years; among women, the greatest number of completed suicides occurs after age 55 years. Rates of 40 per 100,000 population occur in men age 65 years and older. Older persons attempt suicide less often than younger persons but are more often successful. Although they are only 10 percent of the total population, older persons account for 25 percent of suicides. The rate for those 75 years or older is more than three times the rate among young persons.
The suicide rate, however, is rising most rapidly among young persons, particularly males 15 to 24 years of age. The suicide rate for females in the same age group is increasing more slowly than that for males. Among men 25 to 34 years of age, the suicide rate increased almost 30 percent over the past decade. Suicide is the third-leading cause of death in those 15 to 24 years of age, after accidents and homicides, and attempted suicides in this age group number between 1 million and 2 million annually. Most suicides now occur among those aged 15 to 44 years. Suicide is rare before puberty. (For a thorough discussion of this topic see Chapter 45, Mood Disorders and Suicide in Children and Adolescents.)
Race.
Two of every three suicides are white males. White male and female rates are approximately two to three times as high as African-American male and female rates across the life cycle. Among young persons who live in inner cities and certain Native American and Inuit groups, suicide rates have greatly exceeded the national rate. Suicide rates among immigrants are higher than those in the native-born population.
Religion.
Historically, suicide rates among Roman Catholic populations have been lower than rates among Protestants and Jews. The degree of orthodoxy and integration may be a more accurate measure of risk in this category than simple institutional religious affiliation.
Marital Status.
Marriage lessens the risk of suicide significantly, especially if there are children in the home. Single, never-married persons have an overall rate nearly double that of married persons. Divorce increases suicide risk, with divorced men three times more likely to kill themselves as divorced women. Widows and widowers also have high rates. Suicide occurs more frequently than usual in persons who are socially isolated and have a family history of suicide (attempted or real).
Persons who commit so-called anniversary suicides take their lives on the day a member of their family did.
Persons who commit so-called anniversary suicides take their lives on the day a member of their family did.
Occupation.
The higher a person’s social status, the greater the risk of suicide, but a fall in social status also increases the risk. Work, in general, protects against suicide. Among occupational rankings, professionals, particularly physicians, have traditionally been considered to be at greatest risk. Other high-risk occupations include law enforcement, dentists, artists, mechanics, lawyers, and insurance agents. Suicide is higher among the unemployed than among employed persons. The suicide rate increases during economic recessions and depressions and decreases during times of high unemployment and during wars.
Climate.
No significant seasonal correlation with suicide has been found. Suicides increase slightly in spring and fall but, contrary to popular belief, not during December and holiday periods.
Physical Health.
The relation of physical health and illness to suicide is significant. Previous medical care appears to be a positively correlated risk indicator of suicide: About one third of all persons who commit suicide have had medical attention within 6 months of death, and a physical illness is estimated to be an important contributing factor in about half of suicides.
Factors associated with illness and contributing to both suicides and suicide attempts are loss of mobility, especially when physical activity is important to occupation or recreation; disfigurement, particularly among women; and chronic, intractable pain. Patients on hemodialysis are at high risk. In addition to the direct effects of illness, the secondary effects—for example, disruption of relationships and loss of occupational status—are prognostic factors.
Certain drugs can produce depression, which may lead to suicide in some cases. Among these drugs are reserpine (Serpasil), corticosteroids, antihypertensives, and some anticancer agents. Alcohol-related illnesses, such as cirrhosis, are associated with higher suicide rates.
Mental Illness.
Almost 95 percent of all persons who commit or attempt suicide have a diagnosed mental disorder. Depressive disorders account for 80 percent of this figure, schizophrenia accounts for 10 percent, and dementia or delirium for 5 percent. Among all persons with mental disorders, 25 percent are also alcohol dependent and have dual diagnoses. Persons with delusional depression are at highest risk of suicide. A history of impulsive behavior or violent acts increases the risk of suicide, as does previous psychiatric hospitalization for any reason. Among adults who commit suicide, significant differences between young and old exist for both psychiatric diagnoses and antecedent stressors. Diagnoses of substance abuse and antisocial personality disorder occurred most often among suicides in persons less than 30 years of age, and diagnoses of mood disorders and cognitive disorders most often among suicides in those age 30 years and older. Stressors associated with suicide in those younger than 30 years were separation, rejection, unemployment, and legal troubles; illness stressors most often occurred among suicide victims older than 30 years.
Psychiatric Patients.
Psychiatric patients’ risk for suicide is 3 to 12 times that of nonpatients. The degree of risk varies, depending on age, sex, diagnosis, and inpatient or outpatient status. Male and female psychiatric patients who have at some time been inpatients have 5 and 10 times higher suicide risks, respectively, than their counterparts in the general population. For male and female outpatients who have never been admitted to a hospital for psychiatric treatment, the suicide risks are 3 and 4 times greater, respectively, than those of their counterparts in the general population. The higher suicide risk for psychiatric patients who have been inpatients reflects that patients with severe mental disorders tend to be hospitalized—for example, patients with depressive disorder who require electroconvulsive therapy (ECT). The psychiatric diagnosis with greatest risk of suicide in both sexes is a mood disorder.
Those in the general population who commit suicide tend to be middle-aged or older, but studies increasingly report that psychiatric patients who commit suicide tend to be relatively young. In one study, the mean age of male suicides was 29.5 years and that of women suicides was 38.4 years. The relative youthfulness of these suicide cases was partly because two early-onset, chronic mental disorders—schizophrenia and recurrent major depressive disorder—accounted for just more than half of these suicides and so reflected an age and diagnostic pattern found in most studies of psychiatric patient suicides.
A small but significant percentage of psychiatric patients who commit suicide do so while they are inpatients. Most of these do not kill themselves in the psychiatric ward itself, but on the hospital grounds, while on a pass or weekend leave, or when absent without leave. For both sexes, the suicide risk is highest in the first week of the psychiatric admission; after 3 to 5 weeks, inpatients have the same risk as the general population. Times of staff rotation, particularly of the psychiatric residents, are periods associated with inpatient suicides. Epidemics of inpatient suicides tend to be associated with periods of ideological change on the ward, staff disorganization, and staff demoralization.
The period after discharge from the hospital is a time of increased suicide risk. A follow-up study of 5,000 patients discharged from an Iowa psychiatric hospital showed that in the first 3 months after discharge, the rate of suicide for female patients was 275 times that of all Iowa women; the rate of suicide for male patients was 70 times that of all Iowa men. Studies show that one third or more of depressed patients who commit suicide do so within 6 months of leaving a hospital; presumably they have relapsed.
The main risk groups are patients with depressive disorders, schizophrenia, and substance abuse and patients who make repeated visits to the emergency room. Patients, especially those with panic disorder, who frequent emergency services also have an increased suicide risk. Thus, mental health professionals working in emergency services must be well trained in assessing suicidal risk and making appropriate dispositions. They must also be aware of the need to contact patients at risk who fail to keep follow-up appointments.
DEPRESSIVE DISORDERS.
Mood disorders are the diagnoses most commonly associated with suicide. The psychopharmacological advances of the past 25 years may have reduced the suicide risk among patients with depressive disorder. Nevertheless, the age-adjusted suicide rates for patients with mood disorders have been estimated to be 400 per 100,000 for male patients and 180 per 100,000 for female patients.
More patients with depressive disorders commit suicide early in the illness than later; more depressed men than women commit suicide; and the chance of depressed persons’ killing themselves increases if they are single, separated, divorced, widowed, or recently bereaved. Patients with depressive disorder in the community who commit suicide tend to be middle-aged or older.
Social isolation enhances suicidal tendencies among depressed patients. This finding is in accord with the data from epidemiological studies showing that persons who commit suicide may be poorly integrated into society. Suicide among depressed patients is likely at the onset or the end of a depressive episode. As with other psychiatric patients, the months after discharge from a hospital are a time of high risk.
Regarding outpatient treatment, most depressed suicidal patients had a history of therapy; however, less than half were receiving psychiatric treatment at the time of suicide. Of those who were in treatment, studies have shown that treatment was less than adequate. For example, most patients who received antidepressants were prescribed subtherapeutic doses of the medication.
SCHIZOPHRENIA.
The suicide risk is high among patients with schizophrenia: Up to 10 percent die by committing suicide. In the United States, an estimated 4,000 patients with schizophrenia commit suicide
each year. The onset of schizophrenia is typically in adolescence or early adulthood, and most of these patients who commit suicide do so during the first few years of their illness; therefore, those patients with schizophrenia who commit suicide are young.
each year. The onset of schizophrenia is typically in adolescence or early adulthood, and most of these patients who commit suicide do so during the first few years of their illness; therefore, those patients with schizophrenia who commit suicide are young.
Thus, the risk factors for suicide among patients with schizophrenia are young age, male gender, single marital status, a previous suicide attempt, a vulnerability to depressive symptoms, and a recent discharge from a hospital. Having three or four hospitalizations during their 20s probably undermines the social, occupational, and sexual adjustment of possibly suicidal patients with schizophrenia. Consequently, potential suicide victims are likely to be male, unmarried, unemployed, socially isolated, and living alone—perhaps in a single room. After discharge from their last hospitalization, they may experience a new adversity or return to ongoing difficulties. As a result, they become dejected, experience feelings of helplessness and hopelessness, reach a depressed state, and have, and eventually act on, suicidal ideas. Only a small percentage committed suicide because of hallucinated instructions or a need to escape persecutory delusions. Up to 50 percent of suicides among patients with schizophrenia occur during the first few weeks and months after discharge from a hospital; only a minority commit suicide while inpatients.
ALCOHOL DEPENDENCE.
Up to 15 percent of all alcohol-dependent persons commit suicide. The suicide rate for those who are alcoholic is estimated to be about 270 per 100,000 annually; in the United States, between 7,000 and 13,000 alcohol-dependent persons commit suicide each year.
About 80 percent of all alcohol-dependent suicide victims are male, a percentage that largely reflects the sex ratio for alcohol dependence. Alcohol-dependent suicide victims tend to be white, middle-aged, unmarried, friendless, socially isolated, and currently drinking. Up to 40 percent have made a previous suicide attempt. Up to 40 percent of all suicides by persons who are alcohol dependent occur within a year of the patient’s last hospitalization; older alcohol-dependent patients are at particular risk during the postdischarge period.
Studies show that many alcohol-dependent patients who eventually commit suicide are rated depressed during hospitalization and that up to two thirds are assessed as having mood disorder symptoms during the period in which they commit suicide. As many as 50 percent of all alcohol-dependent suicide victims have experienced the loss of a close, affectionate relationship during the previous year. Such interpersonal losses and other types of undesirable life events are probably brought about by the alcohol dependence and contribute to the development of the mood disorder symptoms, which are often present in the weeks and months before the suicide.
The largest group of male alcohol-dependent patients is composed of those with an associated antisocial personality disorder. Studies show that such patients are particularly likely to attempt suicide; to abuse other substances; to exhibit impulsive, aggressive, and criminal behaviors; and to be found among alcohol-dependent suicide victims.
OTHER SUBSTANCE DEPENDENCE.
Studies in various countries have found an increased suicide risk among those who abuse substances. The suicide rate for persons who are heroin dependent is about 20 times the rate for the general population. Adolescent girls who use intravenous substances also have a high suicide rate. The availability of a lethal amount of substances, intravenous use, associated antisocial personality disorder, a chaotic lifestyle, and impulsivity are some of the factors that predispose substance-dependent persons to suicidal behavior, particularly when they are dysphoric, depressed, or intoxicated.
PERSONALITY DISORDERS.
A high proportion of those who commit suicide have various associated personality difficulties or disorders. Having a personality disorder may be a determinant of suicidal behavior in several ways: by predisposing to major mental disorders such as depressive disorders or alcohol dependence; by leading to difficulties in relationships and social adjustment; by precipitating undesirable life events; by impairing the ability to cope with a mental or physical disorder; and by drawing persons into conflicts with those around them, including family members, physicians, and hospital staff members.
An estimated 5 percent of patients with antisocial personality disorder commit suicide. Suicide is three times more common among prisoners than among the general population. More than one third of prisoner suicides have had past psychiatric treatment, and half have made a previous suicide threat or attempt, often in the previous 6 months.
ANXIETY DISORDER.
Uncompleted suicide attempts are made by almost 20 percent of patients with a panic disorder and social phobia. If depression is an associated feature, however, the risk of completed suicide rises.
Previous Suicidal Behavior.
A past suicide attempt is perhaps the best indicator that a patient is at increased risk of suicide. Studies show that about 40 percent of depressed patients who commit suicide have made a previous attempt. The risk of a second suicide attempt is highest within 3 months of the first attempt.
Depression is associated with both completed suicide and serious attempts at suicide. The clinical feature most often associated with the seriousness of the intent to die is a diagnosis of a depressive disorder. This is shown by studies that relate the clinical characteristics of suicidal patients with various measures of the medical seriousness of the attempt or of the intent to die. In addition, intent-to-die scores correlate significantly with both suicide risk scores and the number and severity of depressive symptoms. Patients having high suicide intent are more often male, older, single or separated, and living alone than those with low intent. In other words, depressed patients who seriously attempt suicide more closely resemble suicide victims than they do suicide attempters.
ETIOLOGY
Sociological Factors
Durkheim’s Theory.
The first major contribution to the study of the social and cultural influences on suicide was made at the end of the 19th century by the French sociologist Emile Durkheim. In an attempt to explain statistical patterns, Durkheim divided suicides into three social categories: egoistic, altruistic, and anomic. Egoistic suicide applies to those who are not strongly integrated into any social group. The lack of family integration explains why unmarried persons are more vulnerable to suicide than married ones and why couples with children are the best-protected group. Rural communities have more social integration than urban areas and, thus, fewer suicides. Protestantism is a less cohesive religion than Roman Catholicism, and so Protestants have a higher suicide rate than Catholics.
Altruistic suicide applies to those susceptible to suicide stemming from their excessive integration into a group, with suicide being the outgrowth of the integration—for example, a Japanese soldier who sacrificed his life in battle during World War II. Anomic suicide applies to persons whose integration into society is disturbed so that they cannot follow customary norms of behavior. Anomie explains why a drastic change in economic situation makes persons more vulnerable than they were before their change in fortune. In Durkheim’s theory, anomie also refers to social instability and a general breakdown of society’s standards and values.
Psychological Factors
Freud’s Theory.
Sigmund Freud offered the first important psychological insight into suicide. He described only one patient who made a suicide attempt, but he saw many depressed patients. In his paper “Mourning and Melancholia,” Freud stated his belief that suicide represents aggression turned inward against an introjected, ambivalently cathected love object. Freud doubted that there would be a suicide without an earlier repressed desire to kill someone else.
Menninger’s Theory.
Building on Freud’s ideas, Karl Menninger, in Man against Himself, conceived of suicide as inverted homicide because of a patient’s anger toward another person. This retroflexed murder is either turned inward or used as an excuse for punishment. He also described a self-directed death instinct (Freud’s concept of Thanatos) plus three components of hostility in suicide: the wish to kill, the wish to be killed, and the wish to die.
Recent Theories.
Contemporary suicidologists are not persuaded that a specific psychodynamic or personality structure is associated with suicide. They believe that much can be learned about the psychodynamics of suicidal patients from their fantasies about what would happen and what the consequences would be if they commit suicide. Such fantasies often include wishes for revenge, power, control, or punishment; atonement, sacrifice, or restitution; escape or sleep; rescue, rebirth, reunion with the dead; or a new life. The suicidal patients most likely to act out suicidal fantasies may have lost a love object or received a narcissistic injury, may experience overwhelming affects like rage and guilt, or may identify with a suicide victim. Group dynamics underlie mass suicides such as those at Masada, at Jonestown, and by the Heaven’s Gate cult.
Depressed persons may attempt suicide just as they appear to be recovering from their depression. A suicide attempt can cause a long-standing depression to disappear, especially if it fulfills a patient’s need for punishment. Of equal relevance, many suicidal patients use a preoccupation with suicide as a way of fighting off intolerable depression and a sense of hopelessness. A study by Aaron Beck showed that hopelessness was one of the most accurate indicators of long-term suicidal risk.
Biological Factors.
Diminished central serotonin plays a role in suicidal behavior. A group at the Karolinska Institute in Sweden first noted that low concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the lumbar cerebrospinal fluid (CSF) were associated with suicidal behavior. This finding has been replicated many times and in different diagnostic groups. Postmortem neurochemical studies have reported modest decreases in serotonin itself or 5-HIAA in either the brainstem or the frontal cortex of suicide victims. Postmortem receptor studies have reported significant changes in presynaptic and postsynaptic serotonin-binding sites in suicide victims. Together, these CSF, neurochemical, and receptor studies support the hypothesis that reduced central serotonin is associated with suicide. Recent studies also report some changes in the noradrenergic system of suicide victims.
Genetic Factors.
Suicidal behavior, as with other psychiatric disorders, tends to run in families. For example, Margaux Hemingway’s 1997 suicide was the fifth suicide among four generations of Ernest Hemingway’s family. In psychiatric patients, a family history of suicide increases the risk of attempted suicide and that of completed suicide in most diagnostic groups. In medicine, the strongest evidence for involvement of genetic factors comes from twin and adoption studies and from molecular genetics. Such studies of suicide are reviewed next.
TWIN STUDIES.
A landmark study in 1991 investigated 176 twin pairs in which one twin had committed suicide. In 9 of these twin pairs, both twins had committed suicide. Seven of these 9 pairs concordant for suicide were found among the 62 monozygotic pairs, whereas two pairs concordant for suicide were found among the 114 dizygotic twin pairs. This twin group difference for concordance for suicide (11.3 vs. 1.8 percent) is statistically significant (P < .01).
Another study collected a group of 35 twin pairs in which one twin had committed suicide, and the living co-twin was interviewed. Ten of the 26 living monozygotic co-twins had themselves attempted suicide, compared with 0 of the 9 living dizygotic co-twins (P < .04). Although monozygotic and dizygotic twins may have some differing developmental experiences, these results show that monozygotic twin pairs have significantly higher concordance for both suicide and attempted suicide, which suggests that genetic factors may play a role in suicidal behavior.
MOLECULAR GENETIC STUDIES.
Tryptophan hydroxylase (TPH) is an enzyme involved in the biosynthesis of serotonin. A polymorphism in the human TPH gene has been identified, with two alleles—U and L. Because low concentrations of 5-HIAA in CSF are associated with suicidal behavior, it was hypothesized that such individuals may have alterations in genes controlling serotonin synthesis and metabolism. It was found that impulsive alcoholics, who had low CSF 5-HIAA concentrations, had more LL and UL genotypes. Furthermore, a history of suicide attempts was significantly associated with TPH genotype in all of the violent alcoholics; 34 of the 36 violent subjects who attempted suicide had either the UL or LL genotype. Thus, it was concluded that the presence of the L allele was associated with an increased risk of suicide attempts.
Furthermore, a history of multiple suicide attempts was found most often in subjects with the LL genotype and to a lesser extent among those with the UL genotype. This led to the suggestion that the L allele was associated with repetitive suicidal behavior. The presence of one TPH*L allele may indicate a reduced capacity to hydroxylate tryptophan to 5-hydroxytryptophan in the synthesis of serotonin, producing low central serotonin turnover and, thus, a low concentration of 5-HIAA in CSF.
Parasuicidal Behavior
Parasuicide is a term introduced to describe patients who injure themselves by self-mutilation (e.g., cutting the skin) but usually do not wish to die. Studies show that about 4 percent of all patients in psychiatric hospitals have cut themselves; the female-to-male ratio is almost 3:1. The incidence of self-injury in psychiatric patients is estimated to be more than 50 times that in the general population. Psychiatrists note that so-called cutters have cut themselves over several years. Self-injury is found in about 30 percent of all abusers of oral substances and 10 percent of all intravenous users admitted to substance-treatment units.
These patients are usually in their 20s and may be single or married. Most cut delicately, not coarsely, usually in private with a razor blade, knife, broken glass, or mirror. The wrists, arms,
thighs, and legs are most commonly cut; the face, breasts, and abdomen are cut infrequently. Most persons who cut themselves claim to experience no pain and give reasons, such as anger at themselves or others, relief of tension, and the wish to die. Most are classified as having personality disorders and are significantly more introverted, neurotic, and hostile than controls. Alcohol abuse and other substance abuse are common, and most cutters have attempted suicide. Self-mutilation has been viewed as localized self-destruction, with mishandling of aggressive impulses caused by a person’s unconscious wish to punish himself or herself or an introjected object.
thighs, and legs are most commonly cut; the face, breasts, and abdomen are cut infrequently. Most persons who cut themselves claim to experience no pain and give reasons, such as anger at themselves or others, relief of tension, and the wish to die. Most are classified as having personality disorders and are significantly more introverted, neurotic, and hostile than controls. Alcohol abuse and other substance abuse are common, and most cutters have attempted suicide. Self-mutilation has been viewed as localized self-destruction, with mishandling of aggressive impulses caused by a person’s unconscious wish to punish himself or herself or an introjected object.
PREDICTION
Clinicians must assess an individual patient’s risk for suicide on the basis of a clinical examination. Suicide is grouped into highrisk-related and low-risk-related factors (Table 30.1-1). High-risk characteristics include age greater than 45 years, male gender, alcohol dependence (the suicide rate is 50 times higher in alcohol-dependent persons than in those who are not alcohol dependent), violent behavior, previous suicidal behavior, and previous psychiatric hospitalization.
It is important that questions about suicidal feelings and behaviors be asked, often directly. Asking depressed patients whether they have had thoughts of wanting to kill themselves does not plant the seed of suicide. To the contrary, it may be the first opportunity a patient has had to talk about suicidal ideation that may have been present for some time.
TREATMENT
Most suicides among psychiatric patients are preventable because evidence indicates that inadequate assessment or treatment is often associated with suicide. Some patients experience suffering so great and intense, or so chronic and unresponsive to treatment, that their eventual suicides may be perceived as inevitable. Such patients are relatively uncommon, however. Other patients have severe personality disorders, are highly impulsive, and commit suicide spontaneously, often when dysphoric or intoxicated or both.
The evaluation for suicide potential involves a complete psychiatric history; a thorough examination of the patient’s mental state; and an inquiry about depressive symptoms, suicidal thoughts, intents, plans, and attempts. A lack of future plans, giving away personal property, making a will, and having recently experienced a loss all imply increased risk of suicide. The decision to hospitalize a patient depends on diagnosis, depression severity and suicidal ideation, the patient’s and the family’s coping abilities, the patient’s living situation, availability of social support, and the absence or presence of risk factors for suicide.
Inpatient versus Outpatient Treatment
Whether to hospitalize patients with suicidal ideation is the most important clinical decision to be made. Not all such patients require hospitalization; some can be treated on an outpatient basis. However, the absence of a strong social support system, a history of impulsive behavior, and a suicidal plan of action are indications for hospitalization. To decide whether outpatient treatment is feasible, clinicians should use a straightforward clinical approach: Ask patients who are considered suicidal to agree to call when they become uncertain about their ability to control their suicidal impulses. Patients who can make such an agreement with a doctor with whom they have a relationship reaffirm the belief that they have sufficient strength to control such impulses and to seek help.
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