Suicide

Question 1

what gives an increased risk of suicide for:

• age
• behavior
• sex
• race
• social status
• religion
• health
• occupation
• economic condition

Answer 1

higher risk if:

• older adults
• chronic substance abuse/dependence, with history of race/violent behavior
• white males
• socially isolated, unmarried
• Jewish or Protestant
• chronic illness
• professional occupation with low job satisfaction in a recession/depression

Question 2

what are some behavioral science symptom precursors to suicide?

Answer 2

1. anxiety, agitation, panic attacks, insomnia, restlessness
2. irritability, hostility, aggressiveness, impulsivity
3. hypomania and mania
4. hopelessness and helplessness

Question 3

what is the risk triad of suicide?

Answer 3

1. ideation (thinking)
2. intention (wanting)
3. plan (doing)

Question 4

explain the epidemiology of suicide

Answer 4

12/100,000 (increasing in adolescents, decreasing in teens)

• > 30,000 successful out of >600,000 attempts a year
• symptom/complication of many psychiatric disorders, and treatment may increase risk
• almost always due to mental illness (usually depression)
• 11th cause of death in US, and “average” for international rates
• -higher: Scandinavia, Japan, Switzerland, Germany, Austria, Eastern Europe
• -lower: Spain, Italy, Ireland, Egypt, Netherlands

Question 5

age and suicide

Answer 5

children: rare before puberty
adolescents: 3rd leading cause of death (1-2 million/year)
adults: rare increases substantially after 55 yo
elderly: decreases for women, increases for men
- -attempt suicide less often than younger, but usually more successful
- -elderly are 10% of population, but 25% of suicides

Question 6

gender and suicide

Answer 6

• women attempt 4x as much as men, but using less lethal means (overdose), so unsuccessful
• men are successful 3x as much as women by using more violent means (firearms, hanging, jumping)

Question 7

ethnicity and suicide

Answer 7

• African Americans have lower rates than White or Native Americans
• -race gap narrows among male adolescents (esp. if with gun)
• immigrants have higher rates of suicide (both here and in native countries) due to life transition

Question 8

marital status and suicide

Answer 8

• lowest if married, especially if young children at home
• higher rate if separated, divorced, or widowed
• -divorced men are 3x as likely to commit suicide than divorced women
• higher especially if loss of partner occurred in recent past

Question 9

what is an “anniversary suicide”?

Answer 9

person commits suicide on the day a member of their family did

Question 10

religion and suicide

Answer 10

• lower in Catholic and Islamic religions (specifically prohibit in teachings and practice)
• highest in Protestant
• may depend on degree of orthodoxy rather than religion itself

Question 11

occupations and suicide

Answer 11

• of employed persons, rate is higher in professionals than non-professionals
• -due to access to means (drugs, guns)
• fall in social status also increases risk
• higher if unemployed

Question 12

suicide in physicians

Answer 12

• higher in female physicians (highest risk for females)
• -41/100000
• physicians who commit suicide usually have mental disorder, usually depression and/or substance abuse
• usually occurs by substance overdose, due to drug availability and knowledge about toxicity
• psychiatrists are at greatest risk, followed by ophthalmologists and anesthesiologists

Question 13

substance abuse and suicide

Answer 13

• both chronic and acute use

- decrease inhibitions against risk-taking behavior

Question 14

genetics and suicide

Answer 14

• monozygotic > dizygotic twins
• FH is relevant b/c death of a parent by suicide or when child was younger than 11 yo
• -increased risk if loss of parents by divorce in adolescence
• short allele for serotonin transporter (reuptake pump) to convey poor resilence, increased MDD, and suicide risk when faced with stress
• -long allele provides protective resilience

Question 15

climate and suicide

Answer 15

increase slightly in spring and fall, but not during December/holiday periods

Question 16

what is Werther syndrome?

Answer 16

copy cat suicides

Question 17

depression and suicide

Answer 17

~80% of suicide

• especially patients with holelessness (conditions will never improve)
• increased risk after patient is put on antidepressants or in the initial stages of recovery from depression
• -increased energy and clear thinking improve before lifting of depressed mood gives patient capacity to attempt

Question 18

schizophrenia and suicide

Answer 18

~10% of suicides

-50% attempt suicide, 5% lifetime prevalence

Question 19

physical health and suicide

Answer 19

approx 1/3 of people who commit suicide have had medical attention within 6 mo of death

• many visit the PCP within 1 month
• must differentiate between normal desire to avoid pain and abnormal mental state of major depression (both can be risky)

Question 20

victim-precipitated homicide

Answer 20

using others (ex or police) to kill onself
-places the blame on others while killing two birds with one stone)

Question 21

murder-suicide

Answer 21

can occur as part of a pact (usually made by females or elderly couples)

• sometimes may NOT be a pact, but a homicide or coercion
• increasingly common for someone to rampage, then kill oneself

Question 22

suicidal treatment

Answer 22

1. interview about triad (ideation, intent, plans)
2. take good history about risk factors
   - greatest predictor may be past violence
   - despite good technique, predicting who will commit suicide is statistically poor outcome
3. ask about protective things that keep them alive
4. use least restrictive approach
   - add medication to quickly lower anxiety, insomnia, etc.
   - add slower acting antidepressants or psychotherapy
   - increase support (family, more appointments, social supports) to increase connectivity, purpose, and to decrease helplessness, hopelessness
5. send to hospital in dire cases

Question 23

hospitalizing a suicidal patient

Answer 23

1. if a patient is high risk and doesn’t want to be hospitalized, can be detained for 1-63 days (exact duration depends on state law)
   - can’t force patients to take medications once inpatient
2. can extend length of detainment if court involvement
3. physicians can be legally responsible if they don’t recognize a suicidal patient or if they give a patient medicine that is later used in a suicide attempt

Question 24

what should psychiatric notes comment on?

Answer 24

• lethality risk being low, moderate, or high
• plan to mitigate symptom

especially if making suicidal comments

Question 25

antisuicidal Rx?

Answer 25

1. Electroconvulsive therapy
2. ketamine IV or IN is experimental
3. lithium
4. clozapine
5. antidepressants may protect OR increase risks
   - FDA boxed warning for ages up to 24 yo
   - long-term international data