Suicide is largely preventable; yet too often, efforts are only directed toward individuals who are at immediate risk. In the month prior to their deaths, 45% of suicide completers had contact with their primary care provider as compared to 20% who were in contact with mental health providers (Schreiber, Culpepper, & Fife, 2011). It is critical for health care providers to be advocates for this problem and to mobilize the community in reducing and preventing factors that may contribute to suicide. This chapter reviews the facts about suicide, discusses assessment and care of patients who may be suicidal, and addresses the needs of families of these patients. A second, related category of behavior disturbance, non-suicidal self-injury, is addressed in a separate section at the end of the chapter.

Clinical picture

Suicide is the intentional act of killing oneself by any means. A history of suicide attempts puts a person at a high probability of actually completing the suicide in the future, particularly in the 24 months following the attempt. Nock and colleagues (2010) note that while these suicide behaviors are most often associated with other psychiatric disorders, especially major depression, suicidal behaviors share similar pathological features and require similar treatment plans no matter what other disorder is present.

Suicidal intent and behaviors are symptoms that are manifested in association with mood disorders and psychotic disorders. Clinical attention is directed to individuals who exhibit these behaviors because of the serious outcomes that may result.

Epidemiology

In the United States, suicide is the tenth-leading cause of death—38,364 people ended their lives by suicide in 2011 (CDC, National Center for Injury Prevention and Control, 2012). Suicide is the fourth-leading cause of death among children ages 10 to 14, the third-leading cause of death among 15- to 24-year-olds, the fourth-leading cause of death among persons ages to 44, and the eighth-leading cause of death among 45- to 64-year-olds (Centers for Disease Control, 2012).

Attempted suicide or suicidal ideation led to 666,000 annual visits to the emergency room, and outcomes may be catastrophic for the individual. Consider the young man with schizophrenia who is so depressed and confused from his illness that he takes an overdose and kneels down in front of his couch to pray for forgiveness as he dies. His father finds him lifeless. The young man lives, but since he was in a kneeling position for so long, the circulation to his legs was compromised. This necessitated their amputation and led to lifelong physical disability.

It is important to consider that the number of suicides may actually be double or triple those reported due to underreporting in general. Purposefully aiming the car at a bridge abutment and crashing may look like an accident; however, many reported accidents, homicides, and deaths ruled as “undetermined” are actually suicides.

In a study on war veterans, the rate of significant depressive symptoms was 31% higher than that of the general population. According to the Department of Defense, completed suicides of military personnel between 2005 and 2009 accounted for more than 1100 deaths, an average of 1 suicide every 36 hours during the 5-year period (Cassels, 2010). More recent statistics reveal that active-duty military personnel complete suicide at the rate of 1 per day, and when veterans are included in the count, the rate is 1 suicide every 80 minutes (Gibbs & Thompson, 2012). Box 25-1 provides some facts about suicide, including data for specific age groups.

BOX 25-1

SUICIDE FACTS

General

• Suicide is the tenth-leading cause of death for all ages.

• More than 34,000 suicides occur annually in the U.S. This is the equivalent of 105 suicides per day or 1 suicide every 14 minutes.

• The National Violent Death Reporting System examined toxicology tests of those who committed suicide in 16 states; 33.3% tested positive for alcohol and 21% for opiates or prescription painkillers.

Gender statistics

• Males take their own lives at nearly four times the rate of females and represent 79.8% of all U.S. suicides.

• During their lifetime, women attempt suicide about two to three times more often than men.

• Suicide is the seventh-leading cause of death for males and the fifteenth-leading cause for females.

• Among males, adults aged 75 years and older have the highest rate of suicide (nearly 36.1 per 100,000 population).

• Among females, those in their 40s and 50s have the highest rate of suicide (8.8 per 100,000 population).

• Firearms are the most commonly used method of suicide among males (approximately 56.7%).

• Poisoning is the most common method of suicide for females (37%).

Racial and ethnic statistics

• Among American Indians/Alaska Natives ages 15 to 34 years, suicide is the second-leading cause of death.

• Suicide rates among American Indian/Alaskan Native adolescents and young adults ages 15 to 34 (31 per 100,000) are 2.5 times higher than the national average for that age group (12 per 100,000).

• Of female students in grades 9 to 12, significantly more Hispanic (13.5%) attempt suicide than black non-Hispanics (9%) and white non-Hispanics (8%).

Age statistics

• In 2011, 16% of U.S. high school students reported that they had seriously considered attempting suicide during the 12 months preceding the survey. About 8% of students reported that they had actually attempted suicide one or more times during the same period.

• Suicide is the third-leading cause of death among 15- to 24-year-olds, accounting for 20% of all deaths annually.

• Suicide is the second-leading cause of death among 25- to 34-year-olds.

• The rate of suicide for adults ages 75 years and older was 16 per 100,000.

Attempted suicide

• In 2011, nearly 500,000 people were treated in emergency departments for self-inflicted injuries.

• There is 1 suicide for every 25 attempted suicides.

Data from Centers for Disease Control and Prevention. (2012). Suicide facts at a glance: 2012. Retrieved from http://www.cdc.gov/violenceprevention/pdf/suicide_dataSheet-2012-a.pdf.

Risk factors

Suicidal ideation is the manifestation of inner pain, hopelessness, and helplessness suffered by individuals. Psychiatric disorders accompany 90% of completed suicides (Brendel et al., 2008, National Institute of Mental Health, 2012). The percentage of completed suicides attributable to specific psychiatric disorders is listed in Table 25-1.

TABLE 25-1

PERCENTAGE OF SUICIDES ATTRIBUTABLE TO PSYCHIATRIC DISORDERS

DISORDERS	PERCENTAGE
Affective illnesses (major depression and bipolar disorder)	50
Drug or alcohol abuse	25
Schizophrenia	10
Personality disorders	5

From Brendel, R. W., Lagomasino, I. T., Perlis, R. H., & Stern, T. A. (2008). The suicidal patient. In T. A. Stern, J. R. Rosenbaum, M. Fava, J. Biederman, & S. L. Rauch (Eds.), Massachusetts General Hospital comprehensive clinical psychiatry (pp. 733–745). St. Louis, MO: Mosby.

It is estimated that two thirds of those who complete suicide are experiencing depression at the time. About 15% of patients who have major depression or bipolar disorder (during the depressed phase) will complete suicide (Brendel et al., 2008). Loss of relationships, financial difficulty, and impulsivity are factors in this population.

Suicide is more than 50 times higher among patients with schizophrenia than in the general population, especially during the first few years of the illness (Limosin et al., 2007). It is the leading cause of early death in this population. About 40% of all patients with schizophrenia attempt suicide at least once; males have a rate of 60%. Up to 10% of these patients die from suicide, usually related to depressive symptoms rather than to command hallucinations or delusions.

Patients with alcohol or substance use disorders also have a higher suicide risk. Years of abuse and comorbidity with depression or antisocial personality disorder are also factors associated with increased risk. Up to 15% of alcohol/substance abusers complete suicide (Sadock & Sadock, 2008). Studies have indicated that 50% of the individuals who end their life by suicide have alcohol in their blood at the time of death. Alcohol, a depressant, tends to dull one’s senses, and individuals who are otherwise ambivalent about whether to end their lives may act on suicidal thoughts.

Suicide is usually accompanied by intensely conflicted feelings of pain, hopelessness, guilt, and self-loathing, coupled with the belief that there are no solutions and that that things will not improve. However, the hope of appropriate treatment to relieve patients” suicidal symptoms does exist, and health care providers are important in communicating this hope with patients.

People who survive serious suicide attempts often report that it is these feelings that fuel the sense of isolation and despair. They describe an all-consuming psychic pain that shuts out thoughts of the loved ones and heartache they will leave behind. To understand this phenomenon, imagine the pain of your hand on a hot stove burner. At that moment, you are unlikely to think of anything but putting an immediate end to the pain. Emotional pain often renders the individual void of thought and without enough motivation to leave a suicide note. Only about 33% of individuals who complete suicide leave a note (Haines et al., 2011).

Besides psychiatric disorders, other risk factors for suicide include the following (Sadock & Sadock, 2008):

• Male gender: Men commit suicide four times more often than women.

• Increasing age: For men, suicide rates peak after the age of 45; for women, rates peak after 55.

• Race: White males commit two out of every three suicides in the United States.

• Religion: Religiosity is associated with decreased rates of suicide. Protestants and Jews have higher rates of suicide than Roman Catholics.

• Marriage: Being married, especially with children in the home, significantly reduces the risk of suicide. Divorced men are more likely than divorced women to kill themselves.

• Profession: Professionals are generally considered at higher risk for suicide, particularly if there is a fall in status. Law enforcement personnel, dentists, artists, mechanics, insurance agents, and lawyers are also at higher risk.

• Physical health: About half of those who complete suicide have physical illnesses. Loss of mobility, disfigurement, and chronic pain are especially associated with suicide.

Since individuals with suicidal ideation are often ambivalent about death, helping them examine alternative actions to reduce their pain is critical. Extensive data are available about risk factors for suicide, based on epidemiological studies and psychological autopsies (i.e., retrospective reviews of the deceased person’s life within several months of death to establish likely diagnoses at the time of death). There is also evidence concerning protective factors (those that tend to reduce risk). Refer to Box 25-2 for a description of significant psychosocial risk and protective factors for suicide.

BOX 25-2

SUICIDE RISK FACTORS AND PROTECTIVE FACTORS

Risk factors

• Suicidal ideation with intent

• Lethal suicide plan

• History of suicide attempt

• Co-occurring psychiatric illness

• Co-occurring medical illness

• History of childhood abuse

• Family history of suicide

• Recent lack of social support (isolation)

• Unemployment

• Recent stressful life event (e.g., death, other loss)

• Hopelessness

• Panic attacks

• Feeling of shame or humiliation

• Impulsivity

• Aggressiveness

• Loss of cognitive function (e.g., loss of impulse control)

• Access to firearms and other highly lethal means

• Substance abuse (without formal disorder)

• Impending incarceration

• Low frustration tolerance

• Sexual orientation issues

Protective factors

• Sense of responsibility to family (spouse, children)

• Pregnancy

• Religious beliefs

• Satisfaction with life

• Positive social support

• Access to health care

• Effective coping skills

• Effective problem-solving skills

• Intact reality testing

Data from American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry, 160(11 Suppl), 12.

EVIDENCE-BASED PRACTICE

SAFE-T: Benchmarking Suicide Risk and Recommendations for Interventions

Fowler, J. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49(1), 81–90.

Problem

Conducting assessments for the relative risk of suicide that are both sensitive and accurate is challenging. After suicide attempts, the assessment, management, and treatment of patients who survive is a challenging task for clinicians.

Purpose of study

The purpose of the study was to evaluate tools for suicide risk assessment that summarize the risk factors, warning signs, and protective factors; benchmark the risk; and suggest targeted interventions when the outcome of the assessment is heightened risk.

Methods

The researcher reviewed the risk and protective factors known from the literature to have the strongest evidence base. The researcher also reviewed recent recommendations in the literature for clinicians to enhance therapeutic alliances with patients and to consider recent situations that contributed to the patient’s suicidal ideation.

Key findings

Risk factors associated with suicide attempts include the following:

• Past suicide attempts remain the strongest consistent predictor of suicide attempts and completed suicide.

• Comorbid psychiatric diagnosis is a greater risk with substance, mood, and personality disorders.

• Single diagnoses of eating disorders and substance abuse disorders have the greatest risk.

• Severity of mental disorder, regardless of the disorder, may be a risk factor.

• Psychological vulnerabilities, including aggressiveness/impulsivity, anxiety, and depressive symptoms, increase the risk.

• Genetic markers; 5-HTT serotonin-gene is a moderate risk factor.

• Demographic factors convey risk, albeit inconsistently. At higher risk are males (who complete more suicides), persons who are unmarried, the elderly, adolescent and young adult age groups, and Caucasian race.

• Diathesis-stress models may confer greater risk where underlying genetic and psychological vulnerabilities may be triggered by environmental stressors.

Warning signs

• Suicidal ideation/plan

• Stressful life events

• Posthospitalization transition

Protective factors

• Religious affiliation/beliefs

• Reasons for living, including social and religious/moral reasons

• Marriage except in high-conflict and violent relationships

• Children in the home except in postpartum depression and extreme financial hardships

• Supportive social networks, including religious and school environments and close familial ties

• Therapeutic contacts, particularly for borderline personality disorders

• Psychotropic medications, including lithium prophylaxis for mood disorders and clozapine for psychotic disorders

• Brief, supportive contacts including caring communication and concern

The assessment tool that encompasses both risk and protective factors, provides the clinician with a tool to benchmark risk, and suggests interventions when the outcome is heightened risk is the Suicide Assessment Five-step Evaluation and Triage (SAFE-T). This tool was established based on sponsored research outcomes from the Substance Abuse and Mental Health Services Administration and the recommendations of the American Psychiatric Association Practice Guidelines (2003). Students are encouraged to download a free pocket guide may be downloaded from http://store.samhsa.gov/product/SMA09-4432. The tool allows the clinician to benchmark relative risk (high, moderate, low) and to develop a treatment plan, in consultation with the patient, to reduce current risk.

Implications for nursing practice

Nurses have an important role in the assessment of suicidal risk in both inpatient and outpatient settings. Assessment of risk factors, warning signs, and protective factors is an ongoing responsibility, as is establishing therapeutic alliances with patients. Nurses are in a unique position to establish therapeutic alliances with patients while communicating care and concern. Use of the SAFE-T risk assessment will provide valuable information for development of a plan of care to keep the patient safe.

Etiology

Biological factors

Suicidal behavior is often prevalent among family members. Margaux Hemingway’s death in 1996 was the fifth suicide among four generations of writer Ernest Hemingway’s (1899-1961) family. Twin and adoption studies suggest the presence of genetic factors in suicide. Suicide rates in twins are higher among monozygotic (identical) twins than among dizygotic (fraternal) twins. Studies found a significantly higher incidence of suicide among biological relatives of adoptees who completed suicide than among the biological relatives of control subjects. With the identification of the human genome, the number of studies examining both protective and risk genetic variants is increasing is number.

Murphy et al. (2011) obtained blood samples for DNA from 159 patients with diagnosed mental disorders (76 suicide attempters and 83 non-attempters). They examined the contribution of individual genetic variants to the prediction of suicide attempters and whether single nucleotide polymorphisms (SNPs) have potential for gene-gene and gene-environmental interactions. The researchers identified four SNPs that were positively associated with suicide attempters when compared to the non-attempter group. Further studies examining the complex relationship of genetic and environmental factors in the suicidal behavior of individuals with mental disorders have promise to provide insight into treatment strategies.

Low serotonin levels are related to depressed mood. Studies have found low levels of serotonin or its metabolites in the cerebrospinal fluid of patients who are suicidal (Brendel et al., 2008). Postmortem exams of individuals who complete suicide also reveal a low level of serotonin in the brainstem or the frontal cortex.

Psychosocial factors

Sigmund Freud originally theorized that suicide resulted from unacceptable aggression toward another person that is turned inward. Karl Menninger added to Freud’s thought by describing three parts of suicidal hostility: the wish to kill, the wish to be killed, and the wish to die (Sadock & Sadock, 2008). Aaron Beck identified a central emotional factor underlying suicide intent: hopelessness. Cognitive styles that contribute to higher risk are rigid all-or-nothing thinking, inability to see different options, and perfectionism (APA, 2003).

Recent theories of suicide have focused on the lethal combination of suicidal fantasies accompanied by loss (love, self-esteem, job, and freedom due to imminent incarceration), rage or guilt, and identification with an individual who completed suicide (copycat suicide). A copycat suicide follows a highly publicized suicide of a public figure, an idol, or a peer in the community. Adolescents are at especially high risk, due to their immature prefrontal cortex, the portion of the brain that controls the executive functions involving judgment, frustration tolerance, and impulse control.

Cultural factors

Cultural factors, including religious beliefs, family values, sexual orientation (see the Considering Culture box), and attitude toward death, have an impact on suicide rates. In 2009, ethnicity was a significant factor in the number of deaths by suicide in the United States. White, non-Hispanics had the highest number of deaths by suicide, about 14 per 100,000. Other groups with high rates of suicide are American Indians and Alaskan Natives, about 12 per 100,000, and Asian or Pacific Islanders, about 6 per 100,000 (Centers for Disease Control, 2012).

CONSIDERING CULTURE

Suicide and Sexual Identity

Suicide among lesbian, gay, and bisexual (LGB) youth is on the rise in the United States. In the 15- to 24-year-old population, suicide is the third-leading cause of death, and LGB youth are more likely to attempt suicide than their heterosexual peers (CDC, National Center for Injury Prevention and Control, 2011). Hatzenbuehler (2012) utilized the Oregon Healthy Teens survey to study youth in the 11^th grade between 2006 and 2008. Of the 33,714 students who participated in the study, about 90% identified themselves as heterosexual, about 1% identified themselves as gay or lesbian, about 3% identified themselves as bisexual, about 2% reported they were not sure about their sexual identity, and 4% did not respond. Of those students who reported their sexual identity, nearly 20% of lesbian and gay youth, and 22% of bisexual youth reported having attempted suicide as compared to only 4% of the heterosexual youth.

In all instances, self-identified lesbian or gay and self-identified bisexual youth reported significantly higher percentages of the suicide risk factors than their heterosexual peers. The study also suggests that an environment that is supportive of LGB results in fewer suicide attempts. A supportive environment includes a higher number of same-sex couples, registered Democrats, the presence of gay-straight alliances in schools, and school policies that protect LGB from discrimination and bullying.

From Hatzenbeuhler, M. (2011). The social environment and suicide attempts in lesbian, gay, and bisexual youth. Pediatrics, 127, 896–903.

Among African Americans, men complete suicide more often than women, and the peak rate occurs in adolescence and young adulthood. Protective factors for this group as a whole include religion and the role of the extended family, both of which provide a strong social support system. Similarly, among Hispanic Americans, Roman Catholic religion (in which suicide is a sin) and the importance given to the extended family decrease the risk for suicide. There is also the philosophy of fatalismo, a belief that divine providence regulates the world; the individual is deemed unable to control adverse events and is more likely to accept misfortune instead of blaming the self.

Among Asian Americans, suicide rates are noted to increase with age. Beliefs that reduce suicide attempts include the adherence to religions that emphasize interdependence between the individual and society (i.e., self-destruction is seen as disrespectful to the group or selfish). The high value given to the reputation of the family, however, may lead to the conclusion that suicide is preferable if it prevents shame to the family. A belief in reincarnation may make death a potentially honorable solution to life problems.

Suicide bombing has grown exponentially in recent years, most recently in the Middle East. While not condoned by Islam, suicide bombers may believe that it is an honor to die in defense of their faith, that real happiness exists beyond this life, and that for martyrs, dying is not real death but an honorable ticket straight to heaven. However, there is debate in the literature regarding the difference between martyrdom and suicide. Further research will bring clarity to how mental health professionals might indeed prevent suicide for those who clearly have personal suicidal intent versus those who choose to conduct suicide bombings for martyrdom’s purpose.

Societal factors

Assisted suicide, as a societal factor, is both a moral and ethical issue. In the United States, Oregon’s Death with Dignity Act of 1994 allowed terminally ill patients to legally seek a physician-assisted suicide. The patient must be thoroughly screened by a physician and deemed to be both terminally ill and psychiatrically sound; however, concern has been raised that as many as 25% of the patients in Oregon who were assisted to die actually have clinical depression (Ganzini & Dobscha, 2008).

In 2009, Washington state also approved legislation allowing physicians to prescribe lethal medication. Montana’s Supreme Court determined that assisted suicide is a medical treatment (Marker & Hamlon, 2010). The Netherlands allows for this practice in nonterminal cases of “lasting and unbearable” suffering (Appel, 2007). Belgium authorizes physician-assisted suicide for nonterminal cases when suffering is deemed to be “constant and cannot be alleviated.” Switzerland, where assisted suicide has been legal since 1918, has the most liberal laws; it allows nonresidents to terminate their lives without a physician involved in the process (Appel, 2007).

The ethical and moral dilemmas in this evolving trend are clear. There are now debates about whether chronic and serious mental illness is no different in the depth and breadth of suffering than chronic and serious physical illness. Until more effective treatment or a cure is found, some individuals who obtain little or no benefit from existing psychiatric treatments may choose to end suffering through suicide. As such, individuals do have the power to end their lives by suicide; however, suicide is an all too often tragic, individual act. Assisted suicide, on the other hand, is not a private act, rather one person facilitating the death of another. The ethical dilemma over assisted suicide will continue as individuals attempt to determine the definition of “terminal illness” as a reason to support assisted suicide (Marker & Hamlon, 2010).