Contemplating Suicide: A Physician's Guide to Dealing with the Suicidal Patient

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Resident & Staff Physician®, April 2005, Volume 0, Issue 0

Suicide is often viewed as "a permanent fix to a temporary problem." Unfortunately, for many individuals, attempting suicide is the answer. Estimates suggest there are from 8 to 25 suicide attempts for every one completion. As more lethal methods are used, the number of completed suicides increases. Physicians often see patients in the month before completion of the act. To provide effective treatment, they must be aware of the risks, particularly the red flags that indicate imminent risk in their patients.

Suicide is often viewed as "a permanent fix to a temporary problem." Unfortunately, for many individuals, attempting suicide is the answer. Estimates suggest there are from 8 to 25 suicide attempts for every one completion. As more lethal methods are used, the number of completed suicides increases. Physicians often see patients in the month before completion of the act. To provide effective treatment, they must be aware of the risks, particularly the red flags that indicate imminent risk in their patients.

J. Dan Johnson, DO, Attending Physician, Emergency Department, Lynchburg General Hospital, Clinical Faculty, Lynchburg Family Medicine, Residency Program; Lisa Riddlebarger, MS, LPC, Mental Health Consultant, Emergency Mental Health Services, Centra Health, Lynchburg, Va

The Suicidal Patient

A35-year-old man with previous episodes of depression presents to the emergency department with thoughts of self-harm. He lost his job 2 weeks ago and his primary care physician prescribed paroxetine (Paxil, Pexeva), 20 mg/day. He reports a recent marital separation and estrangement from his 2 children, and complains of "upset stomach" and concerns about his decreased sex drive. He states that he has 3 to 6 beers a day and has been drinking more frequently over the past few weeks, though he does not feel that it is a problem. He admits not taking the paroxetine as prescribed, because he does not like the way it makes him feel. He denies having an active suicidal plan, adding that he can "contract" for his own safety.

In addition to the emergency department physician, the patient was also seen by a mental health counselor, and a telephone consultation was obtained with the on-call psychiatrist. They all believed he could be discharged and scheduled a follow-up appointment with the psychiatrist within the next few days. He is carefully admonished to adhere to his medication and instructed to increase the dose to 40mg/day. He is also advised to abstain from alcohol.

The next morning, the patient is found dead in his home, with a self-inflicted gunshot wound to the head. Was this a potentially preventable suicide?

Prevalence of Suicide

Suicidal behavior is a common problem that all physicians will encounter. In 2002, there were 509,000 emergency department visits as the result of suicide attempts.1 Suicide is the 11th leading cause of death in the United States.2 According to the National Center for Health Statistics, suicides outnumbered homicides in 2002—31,655 versus 17,638, respectively.2

It is estimated that from 8 to 25 suicide attempts occur for every 1 completion.3 Individuals who have survived lethal attempts tend to have the same clinical and psychological profiles as those who complete suicide. These attempts are known as failed suicides.4 Suicidal behavior can be considered to have 2 dimensions: (1) the degree of lethality or damage suffered from the attempt, and (2) suicidal intent, which includes level of preparedness, the desire to live balanced against the desire to die, and the chances that the attempt will be discovered.4 One study indicates that as many as 50% of successful suicides occur on the first attempt.5 As more fatal methods are used—firearms, potent drugs, hanging—the rate of completed suicide approaches that of attempted suicide.4

Age Matters

Suicide rates vary dramatically by age. In 2002, suicide was the 5th leading cause of death in children and teenagers 5 to 14 years and the third leading cause in those aged 15 to 24.6 It is believed that suicide rates increase so dramatically during the teen years because of increased access to lethal weapons, as well as to alcohol and drugs.7 A recent study identified 4 factors as being most predictive of suicide risk in adolescents: hopelessness, hostility, negative self-concept, and isolation.8 Additional risks include behavioral, mental, or conduct disorders, and a loss or rejection (ie, school-related failure, death of a loved one, breakup with significant other, parents' divorce).7,9

Yet the highest suicide rates in America are among the elderly (ie, ≥65 years), with a rate of 15.6 per 100,000 persons.6 Every 90 minutes in America, a senior citizen commits suicide.10 This age-group accounts for nearly 19% of the nation's suicides.10 Elderly white men over the age of 85 are particularly vulnerable, with 54 suicide deaths per 100,000 persons.6

Depression is one of the most significant predictors of suicide in older adults. It is estimated that 4% of elderly women and 3% of elderly men have major depression.11 It is generally accepted that depressed elderly people are much more likely to kill themselves than their nondepressed counterparts (Table 1).

Several studies have shown that many older adults who commit suicide visit their primary care physician close to the act; 20% within 24 hours, 40% within 1 week, and 70% within 1 month of the suicide.10 Because depression often coexists with other medical conditions (eg, cancer, diabetes, stroke, cardiovascular disease), both physicians and patients may often feel that depression is a natural consequence of these problems. This allows depression to be both underdiagnosed and undertreated. Depression is not a natural consequence of aging. This false belief may help explain the high rates of successful suicide in the elderly.

Comorbidities May Increase Risk

Experts disagree about whether medical conditions increase the risk for suicide. Some believe there is no significantly increased risk unless there is a comorbid psychiatric disorder,4 whereas others have found a high correlation between certain diseases and suicide. In a study of 7500 individuals aged 17 to 39 years, after controlling for factors such as depression or alcohol use, persons with cancer or asthma were 4 times more likely to attempt suicide than their healthy peers.12 Disorders of the central nervous system that tend to be an independent risk factor for suicide include Huntington's disease, epilepsy, head injuries, and cerebrovascular accidents.4 Patients with AIDS are more likely to die from suicide than individuals in the general population. Cerebral pathology is believed to impair restraint or inhibit the desire not to act on suicidal thoughts, thereby increasing risk.4

Up to 90% of people who commit suicide have some form of mental illness or are substance abusers, and approximately two thirds have some form of mood disorder.4 Persons with mood disorders are more likely to suffer from hopelessness and subjective depression.4As a result, they see fewer reasons for living even though they may have no more severe life stressors than do healthy individuals.4 Substance abuse or impulsive personality also increase susceptibility to suicidal ideation. Remember, however, that it is not the psychiatric disorder alone that increases risk but rather the combination of a psychiatric disorder and a stressor, although the stressor may be the onset or worsening of the psychiatric condition.4 Although a multitude of factors may increase a person's stress, suicide and suicidal behavior are not normal responses to stress.

Gender Differences

There are noted differences in suicide rates with respect to gender. Women are 2 to 3 times more likely to attempt suicide than men.13 However, men are more likely to die from suicide than women, at a rate of 4 to 1.6 This ratio rises to more than 5 to 1 in the 15-to 24-year-old age-group.6 White men commit 72% of all suicides.2 Although men have much higher success rates and tend to use more violent methods, women are just as lethal in their intent to die.14

It has been suggested, although no data are available, that men who think about suicide tend to be more decisive and absolute in their thinking and are far more likely to use violent means when they have access to them. Men tend to manifest depression as physical complaints, such as headaches, gastrointestinal distress, or sexual dysfunction. Because they may view depression as a "woman's disease," many do not seek treatment and are less likely to report suicidal ideation to their physician.4

Access to Firearms

Latest data suggest that 57% of all suicides are committed with firearms.2 Owning a gun or having a gun in the home increases the risk of suicide in children and adolescents as well as in adults.15 Cities with stricter enforcement of gun control tend to have lower rates of death from suicide by firearm.16

Practice Promotes Success

Some studies suggest that the best predictor of suicidal behavior is a history of previous suicide attempts.17 Previous suicidal experiences may make suicidal thoughts and behaviors more accessible and active. As individuals engage in a "rehearsal" for suicide, whether real or in their minds, the potential for suicide increases. As "practice" ensues, triggers for suicidal behavior may decrease, causing severity of attempts to increase. As the "taboo" and prohibitive quality of such behaviors diminish, so too may the pain and fear of self-harm.18 Suicide risk in patients who have had previous episodes of nonfatal self-harm is hundreds of times higher than in the general population.19 The correlation between self-harm and later suicide is 0.5% to 2% after 1 year and more than 5% after 9 years.19 Suicidal ideation may also involve an aspect of "resolved suicide planning and preparation," considered a form of practice or rehearsal for an actual suicide. Just because an individual has made an attempt that was unlikely to be successful, this does not mean that person is at low risk for more serious attempts or completed suicide. All suicide attempts must be treated as failed suicides.

The Family Connection

Having a family history of suicide makes an individual 2.5 times more likely to commit suicide.20 The risk is 6 times higher in children of a parent who attempted suicide.21 Genetic studies of suicidality have shown higher rates for monozygotic than dizygotic twins.22 Adoption studies also suggest a genetic component.4 The effects of modeling of suicidal behaviors by important family members may also increase the risk of future suicide by children.4 This is yet another example of the old adage, "It's not what you say, but what you do."

Not surprisingly, childhood pain and trauma—common causes of depression and substance abuse—significantly increase the odds of attempting suicide.23 Traumatic childhood events include physical, emotional, or sexual abuse; substance abuse, mental illness, or incarceration involving family members; and parental domestic violence, separation, or divorce.23

Childhood trauma can lead to feelings of isolation and rejection. The need to belong is not just a desire—it is a basic human need. As an individual endures more and more painful experiences, the odds of attempting suicide increase. One trauma increases a person's risk of attempting suicide by 2-to 5-fold.23 Seven or more traumatic experiences increase risk by 51 times in an adolescent and by 30 times in an adult.23

Role of the Primary Care Physician

It is common for suicidal patients to visit their primary care physician in the weeks before they commit suicide. Patients often disclose information to their physicians that they withhold from a spouse or a close family member. However, a review of studies from around the world shows that many communicate their intentions to friends and relatives in very clear and specific terms.

Physicians often overlook suicide risk or fail to make direct inquiry about factors such as feelings of hopelessness or suicidal thoughts (Table 2). Direct questioning about suicidality can take away much of the mystery, but not all patients willingly admit their intentions. Knowledge of depression and other risk factors is essential to adequately assess the potential for suicide (Table 3).

A reliable suicide assessment cannot be conducted in individuals with serious mental illness or intoxication. Psychotic symptoms that are most prone to pushing a patient to commit suicide include: (1) command hallucinations suggestive of the act, (2) feelings/thoughts of being controlled by outside forces, and (3) preoccupation with religion.24 A patient with an altered perception of reality can be dangerous and impulsive. Such a patient should be transported to a secure facility for further evaluation and probable hospitalization. Assistance by police may be necessary to lessen the risk to the individual and to others.

Ask any patient who admits to suicidal ideation for permission to contact a family member or significant other. Family members can often provide additional valuable insights into how the patient has been acting and thinking. Questions should explore the existence of a suicidal plan, access to lethal means, social support systems, and the patient's judgment. The suicidal person should be constantly attended. If the person has a suicidal plan, access to lethal means, recent social stressors, and/or symptoms suggestive of a psychiatric disorder, immediate hospitalization is mandatory.

Suicidal patients are not always willing to comply with treatment recommendations or able to provide "informed consent" to treatment. It then becomes the responsibility of the physician to protect the patient. Emergency custody or detention orders can be obtained to secure a patient for additional evaluation and observation. Contact with legal authorities may be needed to secure a patient who is unwilling to stay. Physicians should be familiar with the laws and procedures in their state.

For individuals with suicidal ideation who have a plan but no intention of carrying it out, outpatient treatment may be an option after a careful review of stressors.24 Hospitalization should be considered or ruled out. Family or social supports should be contacted to ensure that all lethal means have been removed and that an around-the-clock monitoring system can be established. A combination of medication and outpatient therapy is the most effective treatment in such a case.

Antidepressant Therapy

Outpatient treatment with antidepressants is usually safe as long as the patient is carefully monitored by the physician, even though improvement may not be evident for about 4 to 6 weeks. Patients may actually be at increased risk when their energy increases if depression and feelings of hopelessness persist. Weekly follow-up should continue during this time.

It is important to note that the Food and Drug Administration (FDA) recently issued a warning regarding the treatment of depression with antidepressant medications. Specifically, certain antidepressants were suggested to be associated with an increased risk of suicidality among children and adolescents. The FDA has requested the placement of a "black box" warning for all antidepressants sold in this country, to highlight the potential risk of suicide with these medications. But the FDA has since said the association was not proven.

Currently, the only medication approved for the treatment of depression in children and adolescents is fluoxetine (Prozac). Physicians must be aware of this potential risk regarding suicidality in young persons. When prescribing an antidepressant, be sure to have weekly face-to-face contact with the patient for the first 4 weeks of treatment, followed by bi-weekly office visits for the next 8 weeks, and continued monitoring as clinically needed. Psychiatric referral or consultation is recommended if symptoms continue.

"No-Suicide" Contracts: Physicians Beware

Patients who are not in imminent danger may be asked to contract for safety. Such "no-suicide" contracts may be oral or written and stipulate that the patient will not engage in self-harm. The period is generally short, such as 3 to 7 days, at which time the patient would be reassessed in the office or clinic. If during this period the patient has thoughts of self-harm, the patient agrees to immediately contact the physician. Note that safety contracts have not been proven to prevent suicide.25 They tend to give physicians a false sense of security and in no way provide protection from legal liability.25 Better thought of as a safety plan, they may provide patients with valuable options, including contacting a reliable family member or going to the local emergency department or crisis center.

Legal liability is a concern for the physician working with a suicidal patient. The most common legal action involving psychiatric care is the failure to "reasonably protect patients from harming themselves."26 Once a patient receives any type of psychological treatment, a legal duty of care is created between the 2 parties. For inpatient or outpatient treatment, 2 main issues exist: "foreseeability," or the ability to predict elevated risk, and "reasonable" standard of care, or providing proper intervention.26 The physician must recognize a person's risk, then explore the benefits of taking greater control through hospitalization or by contacting family members. All encounters (eg, office, telephone, e-mail) with the suicidal patient must be thoroughly documented, including treatment recommendations and the efforts made to ensure such recommendations are carried out.27

The Suicidal Patient Revisited

Could the suicide described in the initial scenario have been prevented? An appropriate outpatient plan was initiated. The patient contracted for his own safety, was prescribed an appropriate antidepressant, and agreed to seek follow-up care. Should his constellation of risk factors have placed him in a high-risk category and further measures taken to ensure his safety? The patient suffered many losses in a short period of time, including several involving his identity—his job and his roles as husband and father. Several questions should have arisen. How did the patient lose his job? Was the job loss related to the loss of his family, his depression, or his alcohol abuse? Had he ever been hospitalized or previously attempted suicide? Did he have access to a handgun or other lethal means? Have members of his family ever committed suicide or suffered from depression or substance abuse? Does he have any family or social support? Obtaining this additional information might have provided a basis for urging him to pursue hospitalization.

Given this patient's situation, he would be a candidate for an observation period, perhaps in a 23-hour psychiatric observation unit. This unit would allow him to be evaluated by psychiatrists without requiring a formal admission to a psychiatric unit. Followup care could be arranged and/or family and friends contacted to provide support or monitoring in the event he is returned to the community. It also allows the time needed to determine treatment needs—psychotherapy, substance abuse program, or both. It certainly enables the physician to "err on the side of safety," possibly avoiding the unfortunate ending.

Conclusion

Suicide is a major problem in diverse groups of patients seen by physicians. Physicians must recognize the signs and symptoms of depression and be aware of red flags that denote high risk for committing suicide. Physicians must ask about suicidal thoughts or obtain the assistance of family members if necessary. Helping a patient to seek treatment, make a crisis plan, or arrange for hospitalization may curb one of America's most preventable tragedies.

SELF-ASSESSMENT TEST

1. All these factors are red flags for suicide in a patient with suicidal thoughts, except:

  1. Age 25 to 64 years
  2. Access to firearms
  3. Being a white man
  4. Age 10 to 24 years

2. Which of these statements about suicide is NOT true?

  1. Suicides outnumber homicides
  2. It is the third leading cause of death among individuals aged 15 to 24 years
  3. The highest suicide rates are among adolescents
  4. There are 8 to 25 attempts for every 1 completion

3. Which of these is NOT a common risk factor for suicide in the elderly?

  1. Poor sleep quality
  2. Disability
  3. Serious illness in spouse
  4. Bereavement

4. All the following statements about gender and suicide are true, except:

  1. Women are more likely to attempt suicide than men
  2. Twice as many women die from suicide as men
  3. Four times as many men die from suicide as women
  4. White American men commit almost three fourths of suicides

5. All these statements about comorbidity and suicide are true, except:

  1. Risk is increased by 4-fold in persons with cancer
  2. Persons with AIDS are at increased risk
  3. Huntington's disease is an independent risk factor
  4. The majority of people who commit suicide do not have a psychiatric condition

(Answers at end of reference list)

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Answers:

1. A; 2. C; 3. C; 4. B; 5. D