Suicide

Question 1

Risk triad of suicide?

Answer 1

1. Ideation
2. Intention
3. Plan

Question 2

For age, what are we worried about?

Answer 2

1. Children: suicide rare before puberty
2. Adolescents (15-19): third leading cause of death with 1-2 million suicides annually; can occur in clusters!!)
3. Adults: rate increases substantially after 55 y/o
4. Elderly (will decrease for women, increase for men: attempt suicide less often than younger persons but are usually more successful

Question 3

Gender-wise?

Answer 3

1. Women attempt 4x as much as men (usually use less lethal means like overdose)
2. Men successful 3x as much as women (use more violent means like firearms, hanging, or jumping from high places)

Question 4

Ethnicity-wise?

Answer 4

1. African Americans lower rates than whites
2. Race gap narrowing among males aged 15-19 (especially suicide by gun)
3. Immigrants have higher rates of suicide (both here and in their native countries)

Question 5

Marital status?

Answer 5

1. Lowest if MARRIED, especially if children are in the home
2. Higher rate if SEPARATED, divorced or widowed (divorced men 3x more likely to commit suicide than divorced women)
3. Higher especially if loss of partner occurred in recent past
4. “Anniversary suicide”: person commits suicide on the day a member of their family did

Question 6

Religion?

Answer 6

1. Lower in Catholic and Islamic religions (these religions specifically prohibit suicide in their teachings and practice)
2. Highest in Protestant
3. Might depend more on degree of orthodoxy rather than RELGION itself

Question 7

Occupation?

Answer 7

1. Of employed persons, rate is higher in professionals than non-professionals: could be access to means; higher in physicians, dentists, vets (access to prescription drugs); higher in police (access to guns); higher in musicians and attorneys
2. However, a fall in social status also increases risk
3. If considering employed vs. unemployed: rate higher in unemployed

Question 8

Other risk factors than those listed?

Answer 8

1. Substance abuse (both chronic and acute use; decrease inhibitions against risk-taking behavior)
2. Aggressive and impulsive behavior
3. Genetics (monozygotic > dizygotic twins)
4. FH (think death of parent by suicide, or if the child was younger than 11; increased risk if loss of parent by divorce in adolescence; maybe peer history: copy cat suicides)
5. Climate (increases slightly in spring and fall, but not during December/holiday periods

Question 9

Mental/physical health: issues?

Answer 9

1. Depression (80% of suicides): think patients who are HOPELESS; increased risk if put on antidepressants or in initial stages of recovering from depression because they have increased energy and clear thinking before depressed mood has lifted
2. Schizo (10% of suicides)
3. Physical health (people having med attention within time of suicide, like 6 months); differentiate b/w normal desire to avoid pain and abnormal mental state of major depression

Question 10

Other suicide types?

Answer 10

1. Victim-precipitated homicide (use others to kill oneself, aka cops)
2. Murder-suicide: could occur as pact, like with females or elderly couples; however, ends up NOT being a pact (homicide or coercion instead)

Question 11

Treatment:

Answer 11

1. Interview about triad
2. Take good history about risk factors: think PAST VIOLENCE, but still tough to predict who will commit suicide
3. Ask about PROTECTIVE things that keep them alive
4. Use least restrictive approach: add meds to lower anxiety insomnia; add slower acting antidepressants or psychotherapy; increase support to increase connectivity, purpose, and decrease helplessness, hopelessness

Question 12

Immutable, circumstantial, modifiable risk factors of suicide?

Answer 12

Immutable: patient’s history (loss/trauma, previous attempt, psychiatric illness), FH, demographics (male, unmarried, early 20s), cultural/religious belief about suicide, personality traits

Circumstantial: unemployed, financial difficulties, relationship difficulties, physical illness/injury, chronic physical pain, life transitions, ACCESS TO LETHAL MEANS

Modifiable: DRINKING/DRUG ABUSE, nicotine, unstructured time, perceived stress, current psychiatric illness (depression, alcohol abuse), ANXIETY/PANIC ATTACKS/AGITATION/INSOMNIA, delusions

Question 13

Some symptoms precursors to suicidality?

Answer 13

1. Anxiety, agitation, panic attacks, insomnia, restlessness
2. Irritability, hostility, aggressiveness, impulsivity
3. Hypomania and mania
4. Hopeless, helplessness

Question 14

Risk factors for suicide completion:

Answer 14

Serious earlier attempt, older adults, substance abuse/dependence, history of rage and violent behavior, male, white, socially isolated, parent/close relative committed suicide, Jew or Protestant, present psychotic symptoms, chronic illness, professional, recession or depression, low job satisfaction

Question 15

Epidemiology/Demographics of suicide:

Answer 15

1. almost always due to mental illness, typically DEPRESSION
2. about midpoint for international rates regarding US relative to other countries
3. Most common method is HANGING
4. rate of suicide constant, but increasing in 15-24 yr olds and decreasing in elderly
5. Certain treatments could increase risk (antidepressant, antipsychotics, stimulants, epilepsy meds/mood stabilizers)