All emergency clinicians are faced with patients who are considering suicide, have attempted suicide, or are at high risk for doing so. As the 10th leading cause of death in North America, suicide is an omnipresent issue, and the ED is the location of many encounters for patient with suicide attempts, thoughts, and intentions.
Often individuals will readily disclose that suicide is in their thoughts, but many times they come to the ED with unusual injuries, drug ingestions, or other complaints, and the reason is uncovered in the ED. It is a somewhat formidable task for the emergency physician to identify potentially suicidal patients, and it is even more difficult to figure out what to do with them.
Fazel S, Runeson B
N Engl J Med.
This article reviews risk factors for suicide, how to assess suicide risk, and which interventions reduce that risk. Some general facts about suicide are listed in the table.
The World Health Organization estimates that the suicide rate is 10.5 per 100,000 persons and that 79 percent of suicides occur in low- to middle-income countries. (Sept. 2, 2019; https://bit.ly/2YWfP0J.) Europe has the highest rate, Eastern Mediterranean countries the lowest. It is likely that the variation is due to social and cultural attitudes, access to lethal means, and the adequacy of treatment for mental disorders or suicidal thoughts.
Worldwide, suicide rates vary according to age and sex, and suicide rates are highest among elderly men. The rates have been declining, with a near 20 percent reduction in suicides between 2000 and 2016 except in the United States, where the rate increased by 1.5 percent every year since 2000 and where it is 30 per 100,000 in older men. Some potential tools to decrease suicide rates include restricting alcohol, common means of suicide, and the availability of firearms.
Self-injurious behavior associated with an intent to die is termed a suicide attempt, and there are 20 attempts for each death. Among individuals who attempt suicide, 1.6 percent die by suicide within one year and 3.9 percent die by suicide within five years.
Identifying risk factors for suicide is a complex and difficult task. Psychiatric disorders have the strongest effect on suicide, and depression, bipolar disorders, schizophrenia, and traumatic brain injury increase the odds of a completed suicide threefold. Other predisposing risk factors include a previous attempt, childhood sexual abuse, a family history of suicidal behavior, and the loss of a parent to suicide in early childhood. Obtaining this type of information in the ED is difficult, and is not covered by the basic questions asked during ED evaluations. Mood disorders and substance abuse disorders were major risk factors for those who died by suicide, and mental illness, particularly in high-income countries, is present in about half of those who die by suicide.
Depression and bipolar disorders are the most common psychiatric disorders, and they account for approximately half of all suicides. Those with a predisposition for suicide often attempt it in the presence of precipitating factors, such as feeling alone, hopeless, and burdensome and experiencing social isolation combined with access to lethal means. Relationship difficulties, such as separation or divorce, death of a partner, and death by suicide of someone close, particularly a family member, often precede suicide and suicide attempts.
Chronic medical conditions can also be precipitating factors. Suicide is particularly common in the first week after a cancer diagnosis. Suicide is also higher among assault victims, those who have been arrested, and prisoners. Suicidal ideation is magnified by impulsivity and aggression in susceptible people, and both increase the likelihood of acting on suicidal thoughts. Impulsivity is a component of most suicides or suicidal thoughts. A family history of suicide, particularly of a parent when the individual was young, increases the risk. After media reports of suicide deaths in celebrities, the overall incidence of suicides increases by 13 percent. If the method of suicide by a well-known person is publicized, suicides by that method increase by 30 percent.
The brain of a suicidal individual is complex. It has been postulated that changes in the prefrontal cortex lead to overvaluing social signs of rejection, deficits in emotional response, and poor decision-making. Changes in serotoninergic pathways are also seen.
Assessment and Interventions
Models for predicting suicide are not particularly helpful. In fact, most patients who ultimately die by suicide are predicted to be low-risk by many models. Predicting which patients with suicidal thoughts will die by suicide cannot be achieved with a high degree of sensitivity or specificity. A prior suicide attempt, however, is the strongest single factor predictive of subsequent suicide. Psychiatric illness is also a strong predictor of suicide, and more than 90 percent of patients who die by suicide have a psychiatric diagnosis. About 40 percent of suicides occur in individuals who have been a psychiatric inpatient within the previous year.
Some suicide prevention strategies may be helpful, including restricting access to means of suicide. Hanging accounts for 40 percent of deaths by suicide worldwide and ingestion of a pesticide for up to 20 percent of deaths. Pesticide restriction, however, does not appear to reduce suicides. Erection of barriers and restricting access to places for potential suicide, such as bridges and buildings, and limiting the size of nonprescription medications, have led to some reductions in suicide deaths. Gun restriction has been associated with a lower overall suicide rate. Removing potential ligature points in jails and prisons that present opportunities for hanging has led to some reduction of suicides by prisoners.
Pharmacologic treatment to prevent suicide has not been particularly helpful, but using lithium in patients with bipolar disorders or depression has been associated with some reductions in suicide. Methadone and buprenorphine have also been associated with reduced risk of suicide in individuals with opioid drug addiction. Psychological treatments to prevent suicide by addressing suicidal ideation and thoughts and focusing on relieving depression and anxiety have been only minimally effective. Some forms of cognitive therapy have reduced the rate of suicide, but the effect is small and often diminishes after treatment has ceased. The risk of suicide can be managed through regular psychological therapy and pharmacologic means.
Comment: Suicide is a complex multidimensional event with numerous contributing and confounding factors. One person in the United States dies by suicide every 16 minutes. A focused ED evaluation, usually not possible in a busy ED, can often identify suicidal patients, but preventing future suicides or conducting other forms of treatment is difficult, if not nearly impossible, for the emergency clinician.
Helpful psychiatric resources are limited in many hospitals, and sometimes patients wait days in the ED before contact can be made with a psychiatric facility. It is difficult to ferret out activities associated with suicidal potential, but identifying acts such as making a will, getting one's affairs in order, purchasing a gun, or writing a suicide note can alert the emergency clinician to suicide ideation. It may be difficult, however, to obtain this information. It usually comes from a friend or relative.
Interestingly, a significant number of people see their primary care physician within three weeks of dying by suicide. Often this information is not available in the ED. Suicide is more likely in those who actually have a plan for their death. Occasionally suicidal patients have thoughts of killing others and themselves. There is little that the emergency physician can do about treating alcoholism or drug addiction. One should be particularly cognizant of the potential for suicide in those patients with a bipolar disorder or schizophrenia, especially those recently released from a mental health admission.
Generally, individuals with suicidal thoughts and attempts should not be left alone in the ED. They should be placed in an isolated area, and the room should be cleared of devices that can be used to harm oneself. Obviously, they should be checked for weapons and drugs. Probably the most important thing that emergency clinicians can do is identify patients who have suicidal thoughts and attempts that may not be clinically obvious at first glance. Once the potential for suicide is determined, those individuals should be admitted to the hospital or at least receive a psychiatric evaluation, even if it is in another facility.
Medicating patients in the ED is usually not suggested, although those who are extremely agitated or violent can be treated with the standard medications. Treating an individual's underlying psychiatric illness with medications can be effective in suicidal patients, but the emergency physician's intervention unfortunately will have little effect on the final outcome if an individual is truly intent on suicide. The key is to identify potentially suicidal patients and initiate contact with psychiatry. One problem is an individual who initially had suicidal thoughts but says at the end of the intervention that he is no longer suicidal and wants to go home. Many such patients need to be kept against their will, and this raises the issue of medicolegal action against the clinician who keeps the patient in the ED involuntarily. I would rather be sued for restraining or medicating a potentially suicidal patient than trying to defend his death after he leaves the ED.
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Dr. Robertsis a professor of emergency medicine and toxicology at the Drexel University College of Medicine in Philadelphia. Read the Procedural Pause, a blog by Dr. Roberts and his daughter, Martha Roberts, ACNP, PNP, athttp://bit.ly/EMN-ProceduralPause, and read his past columns athttp://bit.ly/EMN-InFocus.