Suicide Prevention Strategies

• Suicide rates in the U.S. rose 20% to 30% from 2005 to 2015.
• Family physicians require evidence-based resources for this growing concern.
• Asking high-risk patients about suicidal intent improves outcomes and doesn't increase suicide risk.
• Routine screening lacks sufficient evidence to be supported.
• Patient history elements include intent, plan, means, support availability, previous attempts, and comorbid conditions.
• Inpatient and outpatient management involves ensuring safety, medical stabilization, activating support, and initiating therapy.
• Care plans for chronic suicidal ideation include the same steps, plus referral for specialty care.
• In the event of a completed suicide, physicians should support family and activate risk management systems.

National Suicide Statistics and Prevention

• National suicide rates are increasing.
• Suicide attempts are becoming more lethal.
• Efforts exist to reduce suicide rates, like the Zero Suicide model.
• Zero Suicide focuses on screening and practice guidelines.
• Family physicians report feeling unprepared to treat patients with suicidal symptoms, demonstrating a need for more training.

Epidemiology and Risk Factors

• Suicide caused over 47,000 deaths in the U.S. in 2017.
• Suicide is the second leading cause of death for those aged 10 to 34.
• Overall, suicide is the 10th leading cause of mortality among adults.
• Between 2005 and 2015, suicide rates increased 20% to 30% in the U.S.
• Firearms are the most common method in completed suicides, accounting for about 50%.
• Hanging or suffocation accounts for 28% of suicides.
• Poisoning (including medication overdose) accounts for 14% of suicides.
• Women attempt suicide twice as often as men, but men are nearly four times more likely to die by suicide.
• Men tend to use violent means (firearms, hanging), while women use more passive means (poisoning).
• The highest suicide rates are among people aged 45 to 54 and 75 to 84.
• Suicidal thoughts, plans, and attempts are highest among those aged 18 to 25.
• White people are about twice as likely to die by suicide as Black or Hispanic people.
• Compared to heterosexuals, the rate of suicide is higher by a factor of two in gay men and women.
• Over 40% of transgender people have attempted suicide.
• People in rural areas are more prone to commit suicide, they also tend to use firearms.
• Non-Hispanic American Indian/Alaska Native people living in rural areas also have increased risk of suicide.

Comorbidities and Risk Factors

• A key risk factor for suicide attempts/completion is a comorbid psychiatric illness, especially with prior attempts.
• These include anxiety, mood, psychotic, and substance misuse disorders.
• Those with depressive disorders have the highest risk.
• Substance misuse alone (without psychiatric concerns) is a risk.
• In psychotic disorders, those with schizophrenia with command hallucinations have the highest risk.
• Other risk factors include functional impairment, fear of psychiatric decline, frequent/severe exacerbations, terminal conditions, chronic obstructive pulmonary disease, chronic pain, and traumatic brain injuries.

Evaluation

• The U.S. Preventive Services Task Force says that there isn't enough evidence to know if routinely screening adolescents, adults, and older adults will reduce attempts or mortality
• Tools for screening such as the PHQ-9 (specifically item 9) are available.
• No agreed-upon recommendations stratify suicide risk.
• Risk stratification is a source of controversy in research.
• Meta-analyses found about one-half of low-risk patients ultimately died by suicide.
• Current recommendations emphasize individualized assessment of suicidal ideation's seriousness.
• This assessment incorporates known risk factors.
• It also takes into account factors that are exacerbating thoughts of self-harm.
• Following standards of care for patients expressing suicidal ideation includes reducing access to methods for self-harm like firearms.
• Evidence suggests asking at-risk patients about suicide neither increases attempts nor ideation, and leads to better outcomes Key questions to assess suicidal patients are in Table 2.

Patient Management

• Patients with suicidal ideation who deny suicidal intent, lack a plan/means, and have good social support can be treated as outpatients or referred for therapy.
• With permission, involve family/friends to ensure patient safety and follow-up.
• Crisis planning includes coping skills, social support, and crisis resources.
• Crisis planning is effective in reducing suicidal ideation and days in the hospital.
• Suicide contracts are not an effective means of reducing suicide.
• Inpatient admission should be offered to patients with specific suicide plans who have the means to complete them
• If a patient is referred for admission but not placed in the hospital, they may experience additional stress and the increased feeling of helplessness
• Treatment options include intensive outpatient treatment or partial hospitalization programs.
• If doubt exists for the need of admission, inpatient care is the prudent option.
• Ensure patient safety regardless of setting.
• Arrange appropriate follow-up and enlist social support.
• Caregivers should remove weapons, medications, and monitor patients.
• During inpatient admissions, patients may need to stay in a locked unit.
• Frequent staff contact can provide early identification after additional attempts.
• Involuntary hospitalization might be required if a patient refuses treatment.
• Physicians should review individual state legislation related to involuntary treatment.

Pharmacotherapy

• Lithium can decrease suicide attempts and mortality
• Clozapine (Clozaril) can reduce suicidal behaviors- reserved until other treatments have been used.
• Restriction on clozapine use due to potential for agranulocytosis.
• First-line treatment for mood disorders are often antidepressants.
• FDA boxed warning due to increased suicidality among adolescents and young adults in the early months after starting SSRIs.
• Concern for overdose with antidepressants (Citalopram and venlafaxine)
• Evidence supports using antidepressants to reduce suicidal ideation and attempts
• Need to accompany pharmacotherapy with patient education, monitoring, and limited medication supplies.
• Ketamine has emerging evidence as a pharmacologic intervention because it rapidly reduces depressive symptoms early, but more studies are needed on dosing, administration, and long-term implications.
• Psychological therapy and pharmacotherapy combinations have been shown to be more effective than either alone when treating suicidal ideations.

Long-Term Management

• Patients require follow-up care
• Follow-up with community mental health programs and mental health clinicians has reduced suicide rates in many countries.
• In patients with personality disorders, suicidal gestures and intent may become common.
• Physicians should evaluate for suicide risk and coping resources and help patients problem solve
• Referrals to emergency services and specialty care are recommended if the patient is at high risk

Coping with Completed Suicide

• A completed suicide causes stress for the patient's loved ones and physician, which may include personal and legal ramifications.
• Bereavement after suicide is similar to that after other causes of death.
• Survivors are more likely to feel shame/ blame.
• Physicians should support the family, answer questions, explain underlying causes, give the opportunity to say goodbye, and have follow-up contact with the healthcare system.
• Support groups may also be of benefit.
• When facing an angry family member, document, notify hospital and managed care, and provide condolences.
• Some physicians report descent into a mood disorder if a patient commits suicide
• Physicians may believe they missed warning signs/could have done more to protect their patient
• Physicians at risk of suicidality because of advanced access may need to have access to social, medical and psychological care.