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Suicidality

Definition
  • Suicide risk management refers to the identification, assessment, and treatment of a person exhibiting suicidal behaviour.
  • Suicidal behaviour includes death by suicide, suicide attempt, and suicidal ideation. 
  • The literature also sometimes includes non-suicidal self-harm as a component of suicidal behaviour.
  • There are 5 components to suicide:
    • ideation
    • intent
    • plan
    • access to lethal means
    • history of past suicide attempts
Risk Factors
  • Current suicidal plan
  • Previous suicide attempt
  • Hx of mental disorder, including substance abuse
  • Availability of lethal means
  • Hx of childhood sexual or physical abuse
  • FHx of death by suicide
  • Male gender
  • Prison inmate
  • FHx of psychiatric illness 
  • Physical illness (especially of CNS) and/or physical impairment
  • Marital status (divorced, single, widowed)
  • Professions/occupations (unemployed, self-employed, agricultural workers, medical and dental professionals)
  • Psychosocial stressors
Differential diagnosis
  • Self-harm
    • Self-inflicted injury that is not associated with an implicit or explicit intent to die. 
    • Examples of self-harm behaviours include burning/cutting after an emotionally upsetting event or burning/cutting as a method of manipulation or threat
Epidemiology
  • Suicide is one of the leading causes of death in the US, Canada, UK, Australia, and New Zealand.
  • In people ages 15 to 44 years, self-inflicted injury is the fourth leading cause of death and the sixth leading cause of ill health and disability worldwide, making suicide a significant public health concern.
  • Suicide is usually more common among males than females, but the opposite is true for suicide attempts. [1] [2]
    • In 2005, the suicide rate among males in the US was 4 times larger than the rate among females. [1] 
    • However, the rate of lifetime suicide attempts among females outnumbers the rate for males. [2] 
  • The discrepancy between men and women with respect to death by suicide may result from the method choice
    • Men tend to choose more lethal methods such as firearms and hanging rather than poisoning or cutting, which are favoured by women. [2] 
    • In addition, the higher rate of female suicide attempts may in part be due to self-harm behaviours (more common among females) being coded as suicide attempts.
  • Suicide is frequently reported as the most common cause of death in correctional settings. As a group, inmates have higher suicide rates than their community counterparts. [3]
  • Male suicide rates are highest in post-communist countries such as Lithuania (68.1/100,000), Belarus (63.3/100,000), and Russia (58.1/100,000)
  • Female suicide rates are highest in Asian countries such as China (14.8/100,000), Korea (14.1/100,000), and Japan (13.1/100,000). [4] 
  • Rate variations are similarly substantial in different regions of the same country, even in Western states.
    • For example, Canadian suicide rates range from a high of 364.4/100,000 to a low of 6.5/100,000 across the administrative regions of provinces and territories. [5]
  • In developed countries, the suicide rate is high for people in midlife and in older people, whereas in developing countries it is highest in people <30 years of age. [6] 
  • The male-to-female suicide ratio also differs, with more females committing suicide in some developing countries (e.g., ratio of 3:1 in Canada versus 1.4:1 in China). [6]
  • Therefore, while suicide is a global concern, it must be understood within the local or regional context so that appropriate public health and clinical responses can be developed and effectively implemented.
Aetiology
  • Suicide results from a constellation of psychological, biological, genetic, social, and environmental factors.
  • A major component of suicide is mental illness, and studies report that up to 90% of people who commit suicide have a diagnosed psychiatric disorder. [9]
    • The 2 most prevalent mental disorders associated with suicide are major depressive disorder and substance abuse. [10] [11] [12] 
  • However, different psychiatric disorders bring different levels of risk for suicide.
  • Physical disorders have also been studied in relation to increased suicide risk.
    • Increased rates of suicide have been reported in Huntington's disease, epilepsy, and after neurosurgery.
  • Other medical illnesses associated with increased suicide risk include HIV/AIDS, cancer (especially of lung and upper airway, GI tract, CNS, lymphoreticular system, pancreas, and kidney), multiple sclerosis, peptic ulcer disease, renal disease, spinal cord injury, and SLE. [13]
  • Medical illness and increased risk of suicide are thought to be associated in part through the presence of a concurrent mental illness.
    • Brain injury may result from substance abuse or suicide attempt;
    • A change in brain function due to a CNS disorder may lead to mood disturbance or personality disorder
    • Disability, disfigurement, and social alienation may lead to mood disturbance. [13] 
    • Terminal illness diagnosis may induce patients to wish to pre-empt the inevitable on their own terms. [14] 
  • Other research regarding the role of physical illness on suicide has found an independent link between physical illness and suicide attempts even after controlling for a variety of mental disorders. [15] [16]
  • Social disadvantage, non-intact family of origin, parental psychopathology, family history of suicidal behaviour, and history of childhood physical or sexual abuse have also been studied as risk factors for suicide, especially in youth. [17] [18] 
  • Sexual orientation has been implicated as a risk factor for suicide attempt but not death by suicide. [19]
  • Access to lethal means significantly increases risk for death by suicide.
    • The US national mortality follow-back survey showed that the odds of suicide increased 28-fold given the presence of a firearm in the home (odds ratio 27.9, 95% CI 18.7 to 41.4). [23] 
  • The most lethal means of suicide are firearms, with case-fatality rates of about 90%, followed by hanging, strangling, and suffocation. [24] 
  • Drug overdose and cutting are 2 less-lethal methods, with case-fatality rates of 2% and 3%, respectively. [24] 
  • Other methods of suicide are drowning; poisoning by gas, liquid, or solid; burning; jumping in front of moving objects or from a height; and motor vehicle collisions.

Clinical features
  • Previous suicide attempt
    • Frequency
    • Context (e.g., time, setting, planning, substance use, impulsivity, witnesses)
    • Method (lethality of method, insight into lethality)
    • Consequences (medical severity, resulting treatment, psychosocial consequences)
    • Intent (expectation of lethality of method, attitude towards life, feeling about discovery and survival)
  • Current suicide plan
    • In general, suicide plans that are premeditated and well thought out involve the choice of a highly lethal method (e.g., firearm or hanging) and are planned for a setting and time when discovery is unlikely
    • Such plans usually indicate a high suicide risk
  • Access to lethal means
    • The most predictive factors for imminent suicide are the presence of a suicide plan and immediate access to lethal means.
    • The most lethal means of suicide are firearms (case-fatality rate about 90%), followed by hanging, strangling, and suffocation. [24] 
  • Hx of psychiatric disease, including substance abuse
    • It is essential to collect information on the patient's psychiatric history and to conduct a careful psychiatric mental status examination to establish current psychiatric symptoms. 
    • Mental illness is a major component of suicide, with up to 90% of people committing suicide having a psychiatric diagnosis. [9] 
    • The 2 most prevalent mental disorders associated with suicide are major depressive disorder and substance abuse. [10] [11] [12] 
    • Greater risk of suicide is also associated with other mood disorders (e.g., bipolar disorder, schizoaffective disorder), anxiety disorders, and psychotic disorders.
  • FHx of suicide or mental illness
  • Chronic medical illness, disability, or disfigurement
    • A medical history identifies the presence of current medical diagnoses or physical challenges that may increase suicide risk, such as terminal illness, chronic disease, pain, functional impairment, cognitive impairment, loss of sight or hearing, disfigurement, and loss of independence/increased dependency on others.
  • Significant psychosocial factors 
    • Suicide risk factors include actual/perceived interpersonal loss or bereavement, perceived humiliation, legal difficulties, financial difficulties, changes in socioeconomic status (e.g., job loss), housing problems, work/school issues, family problems, marital/relationship troubles, interpersonal/peer group problems, and domestic violence.
    • None of these is a substantial predictor of suicide, but they may contribute to the overall risk profile through their effect on the patient's ability to cope and on the support systems available to the person.
  • Personality and/or maladaptive traits
    • These include poor problem solving skills, impulsivity, poor insight, poor affective control, rigid thinking, dependency, and manipulation.
    • None of these predict suicide but may contribute to overall risk profile through their effect on the patient's ability to cope and on the support systems available to the person.
Pathophysiology
  • Genetic and neuroendocrine studies point to factors involved in serotonin pathways as relevant to suicidal behaviours. [25] 
  • These observations seem to be independent of the serotonin abnormalities found in depression.
  • Genetic studies have focused on serotonin-related genes, including tryptophan hydroxylase, serotonin transporter, 3 serotonin receptors (HTR1A, HTR2A, HTR1B), and the monoamine oxidase promoter. [25] 
  • Other factors with putative involvement in suicidal behaviour:
    • Noradrenergic system (alpha-2-adrenergic receptors, tyrosine hydroxylase, catechol-O-methyltransferase)
    • Dopaminergic system (cerebrospinal fluid homovanillic acid, dopamine receptors)
    • Hypothalamic-pituitary-adrenal axis stress response function. [26]
Investigations
  • Tool for Assessment of Suicide Risk (TASR)
    • Can be used by the assessing clinician in the clinical setting to determine the probability of imminent suicide risk.
    • Has no numeric scoring system or cutoff score that predicts suicide but helps ensure the most important issues pertaining to suicide risk are considered
    • Also provides a good record of details of suicide assessment and can be appended to patient's chart/record in any setting. [60]
Management

a) conservative
  • Immediate action should include removing the means for suicide and ensuring the safety of the patient and others, as well as treating any existing psychiatric disorders. [72]
  • Admission to hospital, or observation in a safe place is generally indicated, though it may not reduce subsequent attempts at self-harm.
  • Dialectical behavioural therapy (DBT)
    • An intensive and long-term intervention featuring a combination of behavioural, cognitive, and supportive elements developed to treat patients with borderline personality disorder

b) medical
  • The long-term effectiveness of lithium therapy in reducing completed and attempted suicide among patients with bipolar and other mood disorders (it may also be helpful in schizoaffective disorder) is well established.[B Evidence]
  • Treatment with the atypical antipsychotic clozapine has been shown to be significantly more effective than olanzapine in preventing suicide attempts in patients with schizophrenia and schizoaffective disorder at high risk for suicide.
  • Antidepressant treatment for major depressive disorder is associated with a substantial decrease in suicide risk. [91] [A Evidence]
    • Commonly used antidepressants include fluoxetine, citalopram, and sertraline (all SSRIs).
c) surgical

Prognosis
  • A significant proportion of those who attempt suicide will eventually die by suicide, usually in the same year as the initial attempt. [106]
    • Furthermore, the greater the number of lifetime suicide attempts, the increased likelihood of death by suicide.
  • Overall, though, statistics show that most people who attempt suicide do not eventually die in this manner.
    • However, this fact should not distract the physician from the seriousness of a patient exhibiting suicidal behaviour.
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