Suicide
(1-20-10)

Basic inquiry: always ask about suicide; use direct, concrete language; asks about attempts as well as ideation; specify number of attempts, methods, outcomes; supports; reasons for living

sample inquiry

A continuum of suicidal behavior

• Thoughts about suicide

passive, intermittent, infrequent, easily dismissed

active, constant, frequent, intrusive

Intent

• Preparation for suicide: precursor behavior

saying goodbye, writing notes, giving away possession

procuring materials for attempt

• Attempts at suicide

lethality

"suicidal gestures"

• Death from suicide

  Lineham has suggested that the population who die from suicide are different in many ways from the population who show suicidal ideation, preparation, or (nonlethal) attempts. She suggested (consistent with usage in Great Britain) reserving the term "suicide" to refer to self inflicted deaths, and using the term "parasuicide" to refer to all nonlethal behavior (thoughts, preparations, attempts which are survived).

  Suicidal behavior needs to be distinguished from "self-injurious behavior" (SIB)/deliberate self-harm (DSM)--deliberately hurting oneself (without the intention to die).

Lethality

The lethality of a suicide attempt can be considered in terms of three characteristics.

• the dangerousness of the method--how likely it is to end your life (some authors refer to this as "lethality" also, sorry for confusion).

• the latency of the method--how quickly the method works (or how much opportunity to change your mind you have.

• the willingness of a person to trigger the method--the cultural/personal acceptability of this method of death.

Risk Factors (Predictors)

Demographic

attempt

female
raised in belief system without pejorative view of suicide

death

male
older age
majority/dominant subculture
occupation (knowledge & access to means)

Trait

child/young adolescent

maladjustment
substance abuse

impulsivity (risk factor for attempt)

older adolescent/adult

substance abuse
psychosis
emotional disorder (depression, mania, panic disorder, anxiety)
chronic medical condition

State

hopelessness
social isolation
pain (adult)
psychological crisis (child & adult)
fatigue/illness
unemployment (adult)

Proximal

intoxication
breakdown of social relationships
breakdown of communication
opportunity (availability of means, isolation)

Special Populations

Schizophrenia

Risk Factors for "Suicidal Events" [defined as hospitalization to prevent a suicide attempt or behavior seen as representing a significant suicide risk] (Meltzer, H.Y., Alphs, L., Green, A.I., et al. (2003). Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry 60, 82-91.)

Previous suicide attempts
Previous hospitalizations to prevent suicide
Current or past substance abuse
Depression
Parkinsonism

Prison Populations

Suicide in prison is the leading cause of death in correctional facilities--causing 400 to 600 deaths a year. For years suicide rates in prisons were reported to be 3 to 9 times higher than the rates in general population. Aggressive efforts during the past decade has reduced the occurrence of suicide in prison; and the wisdom of comparing against a general population standard has been called into question (90+% of prison inmates are male). Suicide rates for males are approximately 18 per 100,000. Suicide rates for males in prison declined from approximately 24 per 100,000 in the 1980's to approximately 18 per 100,000 in 1993 (White, 2004). Highest risk groups are not depressed inmates, but inmates with severe mental disorders (psychosis) involving delusional and paranoid thinking, followed by "inmates in high security institutions serving long sentences who found it impossible to enter or remain in general population (White, 2004, p. 10).

Adolescents

"Parental sexual abuse, offspring sexual abuse, impulsive aggresion, and anxiety disorder are all intercorrelated and all relate to an increased likelihood of offspring mood disorder. Therefore, the factors involved in the transmission of mood disorder and of suicidal behavior are similar. Early identification and treatment of pediatric mood disorder may attenuate the risk of early-onset suicidal behavior. Youths whose parents have a mood disorder and a history of sexual abuse are at particularly high risk of both mood disorder and suicide attmpet, especially when these offspring also experience sexual abuse and have high levels of impulsive aggression. . . . The period of approximately 3 years between the onset of mood disorder and first suicide attempt helps define a window of opportunity in which to identify and treat depressive disorders and in turn prevent the onset of suicidal behavior." (Brent et al., 2004, 1265).

Children

Children of both sexes tend to use high lethality methods (firearms and hanging).