Suicide, Violence, and Other Psychiatric Emergencies
I. Suicide
A. Definition
The word suicide is derived from Latin, meaning “self-murder.” If successful, it is a fatal act that fulfills the person’s wish to die. Various terms used to describe parasuicidal thoughts or behaviors (i.e., suicidality, ideation) should be used with clear meaning and purpose. See Table 25-1 for definitions of terms related to suicide.
Identification of the potentially suicidal patient is among the most critical tasks in psychiatry.
B. Incidence and prevalence
About 35,000 persons commit suicide per year in the United States.
The rate is 12.5 persons per 100,000.
About 250,000 persons attempt suicide per year.
The United States is at the midpoint worldwide in numbers of suicides (e.g., 25 persons per 100,000 in Scandinavian countries). The rate is lowest in Spain and Italy.
C. Associated risk factors.
Table 25-2 lists high- and low-risk factors in the evaluation of suicide risk.
Gender. Men commit suicide three times more often than women. Women attempt suicide four times more often than men.
Method. Men’s higher rate of successful suicide is related to the methods they use (e.g., firearms, hanging), while women more commonly take an overdose of psychoactive substances or a poison.
Age. Rates increase with age.
Among men, the suicide rate peaks after age 45; among women, it peaks after age 65.
Older persons attempt suicide less often but are more successful.
After age 75, the rate rises in both sexes.
Currently, the most rapid rise is among male 15- to 24-year-olds.
Race. In the United States, white males commit two of every three suicides. The risk is lower in nonwhites. Suicide rates are higher than average in Native Americans and Inuits.
Religion. Rate highest in Protestants; lowest in Catholics, Jews, and Muslims.
Marital status. Rate is twice as high in single persons than in married persons. Divorced, separated, or widowed persons have rates four to five times higher than married persons. Divorced men register 69 suicides per 100,000, compared with 18 per 100,000 for divorced women. Death of spouse increases risk. For women, having young children at home is
protective against suicide. Homosexual persons are at higher risk than heterosexuals.
Table 25-1 Definition of Terms
- Suicide—self-inflicted death with evidence (either explicit or implicit) that the person intended to die.
- Suicide attempt—self-injurious behavior with a nonfatal outcome accompanied by evidence (either explicit or implicit) that the person intended to die.
- Aborted suicide attempt—potentially self-injurious behavior with evidence (either explicit or implicit) that the person intended to die but stopped the attempt before physical damage occurred.
- Parasuicidal—patients who injure themselves by self-mutilation (e.g., cutting the skin) but usually do not wish to die.
- Suicidal ideation—thoughts of wanting to die; may vary in seriousness depending on the specificity of suicide plans and the degree of suicidal intent.
- Suicidal intent—subjective expectation and desire to end one’s life.
- Lethality of suicidal behavior—objective danger to life associated with a suicide method or action (e.g., jumping from heights is highly lethal, while cutting wrist is less lethal).
From Assessment and Treatment of Patients with Suicidal Behaviors. The American Psychiatric Association’s Practice Guidelines, 2004.
Table 25-2 Evaluation of Suicide Risk
Variable
High Risk
Low Risk
Demographic and social profile
Age
Over 45 years
Below 45 years
Sex
Male
Female
Marital status
Divorced or widowed
Married
Employment
Unemployed
Employed
Interpersonal relationship
Conflictual
Stable
Family background
Chaotic or conflictual
Stable
Health
Physical
Chronic illness
Good health
Hypochondriac
Feels healthy
Excessive substance intake
Low substance use
Mental
Severe depression
Mild depression
Psychosis
Neurosis
Severe personality disorder
Normal personality
Substance abuse
Social drinker
Hopelessness
Optimism
Suicidal activity
Suicidal ideation
Frequent, intense, prolonged
Infrequent, low intensity, transient
Suicide attempt
Multiple attempts
First attempt
Planned
Impulsive
Rescue unlikely
Rescue inevitable
Unambiguous wish to die
Primary wish for change
Communication internalized (self-blame)
Communication externalized (anger)
Method lethal and available
Method of low lethality or not readily available
Resources
Personal
Poor achievement
Good achievement
Poor insight
Insightful
Affect unavailable or poorly controlled
Affect available and appropriately controlled
Social
Poor rapport
Good rapport
Socially isolated
Socially integrated
Unresponsive family
Concerned family
From Adam K. Attempted suicide. Psychiatric Clin North Am 1985;8:183, with permission.
Table 25-3 Medical and Mental Disorders Associated with Increased Suicide Risk
- AIDS
- Amnesia
- Attention-deficit/hyperactivity disorder (ADHD)
- Bipolar disorder
- Borderline personality disorder
- Delirium
- Dementia
- Dysthymic disorder
- Eating disorders
- Impulse-control disorders
- Learning disability
- Major depression
- Panic disorder
- Posttraumatic stress disorder
- Schizoaffective disorder
- Schizophrenia
- Substance use disorders
- Suicide—self-inflicted death with evidence (either explicit or implicit) that the person intended to die.
Physical health. Medical or surgical illness is a high-risk factor, especially if associated with pain or chronic or terminal illness (Table 25-3).
Mental illness
Depressive disorders. Mood disorders are the diagnoses most commonly associated with suicide. Fifty percent of all persons who commit suicide are depressed. Fifteen percent of depressed patients kill themselves. Patients with mood disorder accompanied by panic or anxiety attacks are at highest risk.
Schizophrenia. The onset of schizophrenia is typically in adolescence or early childhood, and most of these patients who commit suicide do so during the first few years of their illness. In the United States, an estimated 4,000 schizophrenic patients commit suicide each year. Ten percent of persons who commit suicide are schizophrenic with prominent delusions. Patients who have command hallucinations telling them to harm themselves are at increased risk.
Alcohol and other substance dependence. Alcohol dependence increases risk of suicide, especially if the person is also depressed. 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. The suicide rate for persons who are heroin dependent or dependent on other drugs is approximately 20 times the rate for the general population.
Personality disorders. Borderline personality disorder is associated with a high rate of parasuicidal behavior. An estimated 5% of patients with antisocial personality disorder commit suicide, especially those in prisons. Prisoners have the highest suicide rate of any group.
Dementia and delirium. Increased risk in patients with dementia and delirium, especially secondary to alcohol abuse or with psychotic symptoms.
Anxiety disorder. Unsuccessful suicide attempts are made by almost 20% of patients with a panic disorder and social phobia. If depression is an associated feature, the risk of suicide rises. Panic disorder has been diagnosed in 1% of persons who successfully kill themselves.
Other risk factors
Unambiguous wish to die.
Unemployment.
Sense of hopelessness.
Rescue unlikely.
Hoarding pills.
Access to lethal agents or to firearms.
Family history of suicide or depression.
Fantasies of reunion with deceased loved ones.
Occupation: dentist, physician, nurse, scientist, police officer, or farmer.
Previous suicide attempt.
History of childhood physical or sexual abuse.
History of impulsive or aggressive behavior.
Social context. Key features of the epidemiology of suicide, however, can vary among different countries or ethnic groups. For example, in China, women commit suicide more than men. Rates vary from some South American countries reporting rates of 3/100,000 to rates in the Russian Federation of 60/100,000.
D. Management of the suicidal patient.
A general strategy for evaluating and managing suicidal patients is presented in Table 25-4.
Do not leave a suicidal patient alone; remove any potentially dangerous objects from the room.
Assess whether the attempt was planned or impulsive. Determine the lethality of the method, the chances of discovery (whether the patient was alone or notified someone), and the reaction to being saved (whether the patient is disappointed or relieved). Also, determine whether the factors that led to the attempt have changed.
Patients with severe depression may be treated on an outpatient basis if their families can supervise them closely and if treatment can be initiated rapidly. Otherwise, hospitalization is necessary.
The suicidal ideation of alcoholic patients generally remits with abstinence in a few days. If depression persists after the physiological signs of alcohol withdrawal have resolved, a high suspicion of major depression is warranted. All suicidal patients who are intoxicated by alcohol or drugs must be reassessed when they are sober.
Suicidal ideas in schizophrenic patients must be taken seriously because they tend to use violent, highly lethal, and sometimes bizarre methods.
Table 25-4 General Strategy in Evaluating Patients
- Protect yourself
- Know as much as possible about the patients before meeting them.
- Leave physical restraint procedures to those who are trained to handle them.
- Be alert to risks for impending violence.
- Attend to the safety of the physical surroundings (e.g., door access, room objects).
- Have others present during the assessment, if needed.
- Have others in the vicinity.
- Attend to developing an alliance with the patient (e.g., do not confront or threaten patients with paranoid psychoses).
- Know as much as possible about the patients before meeting them.
- Prevent harm
- Prevent self-injury and suicide. Use whatever methods are necessary to prevent patients from hurting themselves during the evaluation.
- Prevent violence toward others. During the evaluation, briefly assess the patient for the risk of violence. If the risk is deemed significant, consider the following options:
- Inform the patient that violence is not acceptable.
- Approach the patient in a nonthreatening manner.
- Reassure and calm the patient or assist in reality testing.
- Offer medication.
- Inform the patient that restraint or seclusion will be used if necessary.
- Have teams ready to restrain the patient.
- When patients are restrained, always closely observe them and frequently check their vital signs. Isolate restrained patients from agitating stimuli. Immediately plan a further approach—medication, reassurance, medical evaluation.
- Inform the patient that violence is not acceptable.
- Prevent self-injury and suicide. Use whatever methods are necessary to prevent patients from hurting themselves during the evaluation.
- Rule out cognitive disorders
- Rule out impending psychosis
- Protect yourself
Patients with personality disorders benefit mostly from empathic confrontation and assistance in solving the problem that precipitated the suicide attempt and to which they have usually contributed.Related posts:
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