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INTRODUCTION — Approximately 37,000 people in the United States  and one million worldwide die by suicide each year , and 650,000 people in the United States receive emergency treatment each year after attempting suicide .
Primary care providers may be in a unique position due to their frequency of interaction with suicidal patients. A review of 40 studies found that over 75 percent of patients who died by suicide had contact with primary care providers within the year of their death, compared with one-third who had contact with mental health services . Similarly, twice as many decedents had contact with primary care providers as mental health services in the month before their suicide (45 versus 20 percent).
Despite this, there are no data to show that screening for suicide in primary care reduces mortality. Additionally, predicting which patients with suicidal thoughts will go on to attempt suicide cannot be achieved with a high degree of sensitivity or specificity [4,5].
Nevertheless, the fact that primary care clinicians see a large portion of the patients who subsequently die by suicide suggests that an approach to case finding based upon risk factors, sensitivity to high-risk situations in depressed patients, and assessment of suicidality in patients being treated for depression are appropriate in the primary care setting, and may uncover occasional patients who make their intent known and are amenable to intervention.
This topic reviews the epidemiology, risk factors, evaluation, initial management, and follow-up of the suicidal patient. Other topics discuss the epidemiology, risk factors evaluation, and management of suicidal ideation and behavior in children and adolescents, as well as the effect of antidepressants on suicide risk in pediatric and adult patients.
EPIDEMIOLOGY — Suicidal ideation (thoughts) and behavior are among the most serious and common psychiatric emergencies. Reported rates of suicide, however, may underestimate the true burden because of misclassification of death due to legal or social stigma and procedural issues related to death registration .
In 2013, 842,000 people in the world died from intentional self-harm; China and India accounted for approximately 50 percent of all suicides . Among 240 causes of death, self-harm was the 14th leading cause of years of life lost in the world. In many areas of the world, self-harm was one of the top 10 causes of years of life lost:
●Australia – 4th leading cause of years of life lost
•Central Europe – 6th
•Eastern Europe – 3rd
•Western Europe – 7th
●India – 9th
●Japan – 5th
●United States – 7th
In addition, suicide in the United States appears to be increasing among middle-aged adults. Age-adjusted suicide rates for adults aged 35 to 64 years increased approximately 28 percent (from 14 to 18 per 100,000) from 1999 to 2010 . By contrast, rates for persons aged 10 to 34 years rose 7 percent and rates for adults ≥65 years of age decreased 6 percent.
Approximately 50 percent of all suicides completed in the United States are accomplished with firearms (57 percent of suicides in males) [9,10]. The second leading method of suicide in the United States is hanging for men and poisoning for women. In many developing countries, pesticide ingestion is responsible for the majority of suicide deaths and may account for 30 percent of suicides globally .
The estimated lifetime prevalence of nonfatal suicidality, based upon a study of community samples from 17 countries (n >84,000 individuals), is as follows :
●Suicidal ideation – 9 percent
●Suicide plans – 3 percent
●Suicide attempts – 3 percent
Other findings from the cross-national study included the following :
●Among individuals with a lifetime history of suicidal ideation, the probability of ever making a plan is approximately 33 percent, and the probability of ever making a suicide attempt is approximately 30 percent.
●Among individuals with a lifetime history of suicidal ideation and a plan, the probability of attempting suicide was approximately 55 percent; among ideators without a plan, the probability of attempting suicide was only 15 percent.
●Consistently across all 17 countries, about 60 percent of the transitions from suicidal ideation to suicide plan, and from plan to suicide attempt, occurred in the first year after onset of suicidal ideation.
RISK FACTORS — A variety of factors are associated with an increased risk of suicide:
History of previous suicide attempts or threats — The strongest single factor predictive of suicide is prior history of attempted suicide . A study of a community sample used medical records from 1986 to 2007 to identify 1490 individuals with a first lifetime suicide attempt reaching medical attention; more than 5 percent (n = 81) perished by suicide . Of the 81, more than half (n = 48, 59 percent) died on the index suicide attempt, and among the 33 individuals who survived the index attempt, 27 (82 percent) killed themselves within one year.
One of every 100 suicide attempt survivors will die by suicide within one year of their index attempt, a risk approximately 100 times that of the general population . Following a suicide attempt, the risk for completed suicide is greatest in patients with schizophrenia, unipolar major depression, and bipolar disorder .
It is estimated that there are 10 to 40 nonfatal suicide attempts for every completed suicide [2,12,16].
Psychiatric disorders — Psychiatric illness is a strong predictor of suicide [12,15]. More than 90 percent of patients who attempt suicide have a psychiatric disorder [16,17], and 95 percent of patients who successfully commit suicide have a psychiatric diagnosis .
Severity of psychiatric illness is associated with risk of suicide. As an example, a meta-analysis found that the lifetime risk of suicide is 8.6 percent in patients who have had a psychiatric inpatient admission involving suicidal ideation, 4 percent in patients who have had a psychiatric admission for an affective disorder without suicidality, 2.2 percent in psychiatric outpatients, and less than 0.5 percent in the general population . Patients who have multiple psychiatric comorbidities appear to be at higher risk than those with uncomplicated depression or an anxiety disorder [20,21].
Suicide may be concentrated in the days and weeks following psychiatric inpatient hospitalization. In one systematic review, 41 percent of those who committed suicide had been psychiatric inpatients within the previous year and as many as 9 percent of suicides occurred within one day of discharge from psychiatric inpatient care . This last figure may have been inflated by including some patients who committed suicide during their inpatient stays.
The psychiatric disorders most commonly associated with suicide include depression, bipolar disorder, alcoholism or other substance abuse, schizophrenia , personality disorders, anxiety disorders including panic disorder, posttraumatic stress disorders, and delirium . Among patients with depression, a history of suicide attempts correlated most strongly with feelings of worthlessness . Concurrent personality disorder was also strongly correlated with suicide attempts in depressed patients.
Anxiety disorders more than double the risk of suicide attempts (odds ratio 2.2)  and a combination of depression and anxiety greatly increases the risk (odds ratio 17) . Symptoms of psychosis (delusions, command auditory hallucinations, paranoia) may increase the risk regardless of diagnosis.
The reported rate of suicide among alcoholics has ranged from 2 to 18 percent [27,28]. Almost 90 percent of alcoholic suicides are committed by men. Of people who commit suicide, approximately 20 to 25 percent are intoxicated . In a Center for Disease Control and Prevention study from 13 states, alcohol was detected in 33.3 percent of suicide victims tested for substance abuse in 2004 . In that same report, 16.4 percent tested positive for opiates.
Hopelessness and impulsivity — Across psychiatric disorders, hopelessness is strongly associated with suicide. As an example, in one multivariate model, hopelessness was 1.3 times more important than depression in explaining suicidal ideation . Hopelessness can persist even when other symptoms of depression have remitted . Hopelessness may mediate the relationship between low self-esteem, loneliness, interpersonal losses, and suicide .
Impulsivity, particularly among adolescents and young adults, is also associated with acting on suicidal thoughts, and the combination of hopelessness, impulsivity, and disinhibition from substance abuse may be particularly lethal .
Age, sex, and race — The risk of suicide increases with increasing age, however young adults attempt suicide more often than older adults [34-36]. Females attempt suicide nearly twice as often as males , but males complete suicide three times more often . These age and sex differences appear to be primarily related to the lethality of the method chosen (eg, firearms, hanging, or falls) rather than a difference in completion rates for the same method .
Elderly white men, aged 85 years and older, have the highest suicide rate (51.6/year per 100,000 population) in the United States . Although suicide rates have been higher among whites than blacks (12 compared with 5 per 100,000 in 2003) , the rate differences between races have been narrowing in recent years, with increasing rates of suicide attempts especially among young black males .
Marital status — Suicide risk varies with marital status . The highest risk occurs among those never married, followed in descending order of risk by widowed, separated, or divorced; married without children; and married with children. Whatever the family structure, living alone increases the risk of suicide .
Occupation — Suicide may be greater in patients who serve in unskilled occupations than skilled occupations . A meta-analysis of 34 studies (sample size not specified) found that the risk of suicide was greater among the least skilled workers (eg, laborers and office cleaners who perform simple manual tasks) than in the general working-age population (rate ratio 1.8, 95% CI 1.5-2.3) . By contrast, the risk of suicide was lower in the most skilled workers (eg, general managers who solve complex problems) than in the general working-age population (rate ratio 0.7, 95% CI 0.5-0.9). In addition, unemployment and economic strain may lead to a higher risk of suicide .
However, among highly skilled workers, physicians may be at increased risk of suicide. A meta-analysis of 25 studies (approximately 2100 suicides among physicians) found that the rate of suicide was greater in female physicians than the general population (standardized mortality ratio 2.3, 95% CI 1.9-2.7), and was also greater in male physicians than the general population (standardized mortality ratio 1.4, 95% CI 1.2-1.7) .
Military service — In the United States, the rate of suicide in military veterans exceeds that of the general population. (See "Medical care of the returning veteran".)
Health — Suicide risk increases with physical illness, including asthma, cancer, chronic obstructive pulmonary disease, coronary artery disease, diabetes mellitus, spine disorders (eg, disc disorders), and stroke, recent surgery, and chronic or terminal disease [48-51]. HIV infection alone does not appear to increase risk . Body mass index and risk of suicide are inversely related in men .
Chronic pain — Chronic pain, independent of other factors such as sociodemographics and physical and mental health status, doubles the risk of suicide behaviors or completed suicide . The risk may be even greater in patients with multiple pain conditions, severe pain, and more frequent episodes of intermittent pain (eg, migraines), as well as those who are unemployed or disabled due to their pain condition.
Adverse childhood experiences — Childhood abuse and other adverse childhood experiences (eg, intimate partner abuse or substance abuse in the home, mentally ill household member, parents separated or divorced, an incarcerated family member) appear to increase the risk of suicide in adults [55-57]. As an example, a meta-analysis of seven prospective observational studies (n >6500 subjects) found that suicide attempts were more than twice as likely to occur in adults who suffered childhood sexual abuse, compared with adults who were not abused . However, the individual studies generally did not control for suicidal behavior prior to or at the time of the abuse, and the association across studies was highly heterogeneous.
Family history and genetics — The risk of suicide increases in patients with a family history of suicide [59,60]. As an example, a national registry study found that if one sibling died by suicide, the risk of remaining siblings doing so was increased both among women (odds ratio 3) and men (odds ratio 2) .
Twin studies suggest that the increased risk of suicide among patients with a family history of suicide has both environmental and genetic components [59,62]. The heritability of suicide is in the range of 30 to 50 percent . However, it is not clear whether the genetic component is primarily responsible for the underlying psychiatric disorder or for the suicide itself. In one study, both a family history of completed suicide and psychiatric illness were risk factors for suicide, and the effect of family suicide history was independent of the family history of psychiatric illness . Additionally, having an unrelated spouse who has a psychiatric disorder or who commits suicide increases the risk of suicide, showing the importance of environmental effects within the family structure .
Firearms — A meta-analysis of 14 observational studies found that the risk of completed suicide was three times greater among individuals with access to firearms, compared to individuals without available firearms . In addition, ecological and other observational studies suggest that restricting access to guns decreases the risk of suicide .
Antidepressants — The potential association of antidepressant therapy in adults with an increased risk of suicide is discussed separately. (See "Effect of antidepressants on suicide risk in adults".)
Other — The risk of suicide increases in patients with accessibility to weapons, especially firearms . Risk also increases in patients who live alone, have lost a loved one, or have experienced a failed relationship within one year ; and possibly in patients with a history of violent behavior in the previous year . The anniversary of a significant relationship loss is also a time of increased risk . Among those widowed, the risk of suicide is highest in the first week after bereavement, decreasing rapidly in the first months thereafter, but remaining elevated throughout the first year following the loss . Homelessness, particularly in those with psychiatric disorders, increases the risk of suicide .
Sociopolitical, cultural, and economic forces can lead to increased suicide rates in populations [2,72]. Violence and political coercion are associated with increased rates of suicide, as are economic downturns [73,74]. Those living in rural areas have higher rates of suicide than those living in urban areas. In a survey of adolescents, those who identified themselves as lesbian, gay, or bisexual reported higher rates of suicidal ideation and suicide attempts than heterosexual respondents . People who score lower on intelligence tests also appear to have a higher risk of suicide . Advancing paternal age, which is associated with increased genetic mutations during spermatogenesis, may increase the risk of suicide attempts in one’s offspring .
PROTECTIVE FACTORS — Social support and family connectedness is protective against suicide, while family discord increases the risk of suicide . As an example, a study of nationally representative samples found that after controlling for several potential confounding factors, social support was associated with a decreased risk of suicide in the United States (odds ratio 0.7) and in England (odds ratio 0.9) . Pregnancy decreases the risk of suicide, as does parenthood , particularly for mothers. Religiosity and participating in religious activities is associated with a lower risk of suicide .
ASSOCIATION WITH VIOLENT CRIMINALITY — Deliberate self-harm in young adults may be associated with an increased risk of aggression toward others. A national registry study identified a cohort of individuals aged 15 to 32 years (n >1,850,000), which included patients who were treated for deliberate self-harm (n >50,000), and examined the association between nonfatal self-harm and subsequent conviction for a violent crime . The mean follow-up period was eight years; violent crimes included homicide, assault, robbery, and threats. After controlling for potential confounding factors (age, psychiatric disorder, and socioeconomic status), the analyses found that conviction of a violent crime occurred twice as often in patients treated for self-harm, compared with the general population (hazard ratio 2.2, 95% CI 2.1-2.2). In addition, the rate among males and females with self-harm was similar (hazard ratio approximately 2).
PATIENT EVALUATION — The purpose of a suicide risk assessment is to review risk and protective factors with a focus on identifying modifiable targets for intervention [82,83].
Clinicians may worry that asking about suicide will initiate suicidal thoughts or actions, but there are no data to support this concern. By contrast, many patients appreciate the opportunity to discuss suicidal thoughts, and may not verbalize these issues without being prompted. Sometimes the only clue to a suicidal patient is the initiation of an office visit.
The observation that patients who subsequently commit suicide have often recently visited primary care clinicians has been interpreted as reflecting help-seeking behavior. However, clinicians may be unaware of their patient's intent. As an example, in one study of depressed suicide victims, 59 percent who were treated in a psychiatric setting had communicated their intent compared with only 19 percent cared for in a medical setting . While patients may be reluctant to communicate their intent to commit suicide, patients with suicidal ideation will generally tell their clinicians about such thoughts when asked .
The evaluation of a patient who may be suicidal includes an assessment of ideation, method, plan, and intent. Unfortunately, our ability to predict who will attempt suicide is limited; patients who die by suicide are similar to those who do not . As an example, one study of 4800 psychiatric inpatients who were evaluated using the risk factors (see 'Risk factors' above) found that trying to identify particular people who would or would not die by suicide was not feasible because of the low sensitivity and specificity of available identification procedures . Similarly, among patients who have presented to an emergency department after an episode of self-harm, assessments by psychiatrists and emergency department staff have low sensitivity and specificity for predicting who will repeat self-harm .
A number of standardized scales have been proposed to evaluate suicide risk, but none is associated with a high predictive value. Depression rating scales are commonly used, but these are better measures of depression severity than suicide risk. As an example, a study evaluated responses to item number nine from the Patient Health Questionnaire – Nine Item (PHQ-9) (form 1) (“Over the last two weeks, how often have you been bothered by thoughts you would be better off dead or of hurting yourself in some way?”), and found that the cumulative risk of suicide over one year among outpatients who answered “nearly every day” was 4 percent . In cardiac inpatients with current emotional distress (n = 366), a positive response to item nine was endorsed by 21 percent, but a detailed suicide evaluation found that suicidal plans or intent were present in only 3 percent .
Another option for identifying patients at high risk of suicide is the Beck Hopelessness Scale, which is a 20-item true/false questionnaire that correlates more closely with current suicide attempt than depression severity. However, a meta-analysis found that the low specificity of the scale limits its applicability .
Suicidal ideation and behavior — The first step in evaluating suicide risk is to determine the presence of suicidal ideation (thoughts), including their content and duration. The questioning should determine whether the patient has active or passive suicidal ideation:
●Active suicidal ideation – Thoughts of taking action to kill oneself. As an example, “I want to kill myself” or “I want to end my life and die.”
●Passive suicidal ideation – The wish or hope that death will overtake oneself. As an example, “I would be better off dead,” “My family would be better off if I was dead,” or “I hope I go to sleep and never wake up.”
If suicidal ideation is present, the clinician should ask if the thoughts are new and about changes in what may be chronic thoughts (eg, increased intensity or frequency), and if or how the patient has been controlling these thoughts. Other inquiries include the patient's expectations about death (including thoughts of reuniting with lost significant others), thoughts of evoking punishment of others, the need to escape a painful physical or psychological situation, or thoughts of harming others first before harming him or herself.
The presence of a suicide plan and the degree of intent to kill oneself can be elicited by asking about the following:
●Has a specific plan been formulated or implemented, including a specific method, place, and time? What is the anticipated outcome of the plan?
●Are the means of committing suicide available or readily accessible? Does the patient know how to use these means?
●What is the lethality of the plan? What is the patient's conception of lethality versus the objective lethality?
●What is the likelihood of rescue?
●Have any preparations been made (eg, gathering pills, changing wills, suicide notes) or how close has the patient come to completing the plan? Has the patient practiced the suicidal act or has an actual attempt already been made?
●What is the strength of the intent to carry out suicidal thoughts and plans?
●Is there a history of impulsive behaviors or substance use that might increase impulsivity? What is the ability to control impulsivity?
●What is the accessibility of support systems and recent stressors that may threaten the patient's ability to cope with difficulties and ability to participate in treatment planning?
Past history — Clinicians should ask about a past history of suicidal ideation and behavior.
Family history — Clinicians should ask about a family history of suicidal ideation and behavior.
Contracting for safety — As part of assessing suicidal ideation, as well as supporting the patient's ability to avoid suicidal behavior, clinicians often ask if the patient can "contract for safety" or agree to a "no harm contract" . The phrases imply that patients can promise clinicians that they will try not to harm themselves when they have suicidal thoughts and will seek help if necessary. The terms are not defined or used consistently, and clinicians generally do not receive formal training in suicide prevention contracts . Despite their wide use, there is little evidence that such contracts actually reduce suicide . Contracting for safety may thus provide a false sense of security. Better tools include open dialogue between patients and clinicians to establish a therapeutic alliance, as well as ongoing assessments of suicide risk over time.
Other factors to evaluate — Clinicians should assess other factors related to suicidal ideation and behavior [82,94]:
●Hopelessness and view of the future
●Helplessness and sense of control
●Current life stressors, such as conflicts at home or work, and coping capacity
●History of aggressive behavior directed at others
●History of psychiatric disorders, including:
•Personality disorders (eg, borderline personality disorder)
•Posttraumatic stress disorder
•Psychotic disorders (eg, schizophrenia)
•Substance use disorders
•Unipolar major depression
●History of general medical conditions such as pain disorders
In addition, observe whether the patient is disconnected, disengaged, or shows a lack of rapport during the clinical interview, because these clinical signs are associated with an increased risk of suicide.
Screening — There is no evidence that routine screening for suicidal ideation in adult primary care patients reduces suicide attempts or mortality. Systematic reviews for the United States Preventive Services Task Force (USPSTF) have concluded that the evidence is insufficient to determine the benefits of screening for suicide risk in the general population of United States adults who do not have existing mental disorders or past histories of suicide attempts [95,96]. The USPSTF clinical practice guideline for screening for suicide risk, as well as other USPSTF guidelines, can be accessed through the website for the Agency for Healthcare Research and Quality.
Similarly, the Canadian Task Force on Preventive Health Care found poor evidence to recommend for or against routine evaluation of suicide risk even in individuals at high risk for suicide, but nevertheless recommends screening of high-risk individuals given the high burden of suffering .
MANAGEMENT — Management of the suicidal individual should include:
●Reducing immediate risk and treatment planning
●Managing underlying factors and psychiatric disorders
●Monitoring and follow-up
Medical stabilization — The first priority for patients who have attempted suicide is medical stabilization at a hospital. The appropriate surgical service should be contacted for management of trauma. Patients whose attempt involved drug ingestion should undergo decontamination and receive antidotes as indicated. (See "Initial management of trauma in adults" and "General approach to drug poisoning in adults" and "Initial management of the critically ill adult with an unknown overdose".)
●Partial hospital (day program)
●Intensive outpatient program (eg, three days/week for three hours/day)
Inpatient hospitalization — Psychiatric inpatient hospitalization for further evaluation and initiation of therapy is nearly always indicated for patients with recent suicidal behavior (eg, suicide attempt) or imminent high risk of suicide (eg, patients with moderate to severe suicidal ideation that includes a plan and intent) .
Factors that can place patients at high risk of suicide include:
●Suicide attempt with a highly lethal method (eg, firearm or hanging)
●Suicide attempt that included steps to avoid detection
●Ongoing suicidal ideation or disappointment that the suicide attempt was not successful
●Inability to openly and honestly discuss the suicide attempt and what precipitated it
●Inability to discuss safety planning (see 'Safety plan' below)
●Lack of alternatives for adequate monitoring and treatment
●Psychiatric disorders underlying the suicidal ideation and behavior:
•Personality disorders (eg, borderline personality disorder)
•Posttraumatic stress disorder
•Psychotic disorders (eg, schizophrenia)
•Substance use disorders
●Poor social support
While awaiting psychiatric inpatient hospitalization, patients should be kept in a room with all sources of potential harm removed and a staff member should be assigned to provide constant observation. The patient's belongings should be stored separately or searched for potential methods for self-harm. Cooperative family members may be present if the patient desires. Security staff may be necessary to detain patients who insist on leaving. Transfer of the patient should take place by ambulance, and the paramedics must be aware of the suicide risk. Efforts should be made to inform the patient's outpatient primary care and mental health clinicians about the impending hospitalization. Inpatient treatment should continue until the patient’s safety has stabilized.
Involuntary hospitalization — If patients do not agree with plans for hospitalization, involuntary hospitalization may be necessary . The process for admitting patients who will not or cannot sign themselves into a hospital vary among countries and from state to state in the United States. Most states require clinicians to certify that the patient is a danger to self or others, or is at imminent risk to come to harm because of an inability to adequately care for oneself.
In the United States, patients who are admitted against their will, or the will of their guardians, maintain the autonomy to consent for treatment. The only medications that can be administered without their consent, or the consent of their guardians, are those that are necessary for stabilization during a behavioral crisis. If daily medications are deemed necessary for treatment of underlying psychiatric disorders, clinicians will need to obtain court ordered treatment.
Partial hospital and outpatient care — Patients in whom the risk of suicide is elevated but not imminent (eg, those with depression or alcohol abuse who express a desire to commit suicide but who do not have a specific plan or intent) need aggressive treatment that generally can be administered in a partial hospital (day program) or in an outpatient clinic. Outpatient therapy is contingent upon a safety plan (figure 1). (See 'Safety plan' below.)
Useful interventions include :
●Involving family members or people close to the patient to regularly monitor the patient until safety has further stabilized
•Provide patients and caregivers 24 hour access to clinical support in case of urgent need.
•Instruct family members that if the patient decompensates, the patient must return to the emergency department; if the patient refuses, the police should be summoned.
•Although patients may object to clinicians reaching out to other people for additional history or help in mitigating the risk of suicide, we maintain that safety trumps confidentiality. In addition, patient reluctance regarding clinical contact with family members is a therapeutic issue that should be assessed. (See "Family and couples therapy for treating depressed adults", section on 'Assessment'.)
●Restricting access to all lethal means of suicide, particularly firearms and medications – Ask about the availability of firearms and medications, and make them temporarily inaccessible to the patient with the help of family members and the police. (See 'Firearms' above.)
●Communicating a commitment to help, and scheduling enough clinical contact such that the patient feels connected and supported.
●Identifying and avoiding triggers for relapse of suicidal ideation and warning signs.
●Educating patients and caregivers about the disinhibiting effects of alcohol and other drugs.
●Specifying coping strategies and healthy activities to manage or distract oneself from suicidal thoughts.
●Treating psychiatric disorders aggressively. (See 'Underlying factors and mental disorders' below.)
Safety plan — As part of supporting the patient's ability to avoid suicidal behavior, clinicians should discuss a safety plan that specifies how patients can cope with recurrent suicidal urges in the future (figure 1). The safety plan is a widely used therapeutic tool. In addition, the extent to which patients can commit to stay safe and use the safety plan provides additional information about their risk for suicidal behavior, and can thus aid the patient evaluation. (See 'Patient evaluation' above.)
Patients who agree to adhere to a safety plan may still be at high risk; this agreement does not protect patients or clinicians, and is not a substitute for thorough evaluation, sound clinical judgment, and meaningful therapeutic interaction, particularly with impulsive patients.
Underlying factors and mental disorders — Once immediate safety has been ensured, clinicians should address underlying factors, including precipitating events, ongoing life difficulties, and mental disorders.
Precipitating events include the death of a loved one, loss of a job, breakup of a marriage, school or social failure, sexual identity crisis, or trauma. In addition, people may attempt suicide as an alternative to intolerable life circumstances, such as abusive relationships, occupational stresses, and chronic isolation (see 'Risk factors' above). Referral for treatment is indicated, and engagement of community, religious, and family supports may also be helpful.
Primary care clinicians should ensure that patients receive appropriate psychiatric treatment. Patients discharged from inpatient psychiatric care are at high short-term risk, particularly if there is a break in the continuity of care. (See 'Monitoring and follow-up' below.)
Pharmacotherapy — For patients with unipolar major depression or bipolar disorder, randomized trials indicate that maintenance treatment with lithium can prevent suicide. A meta-analysis of four trials (485 patients with either unipolar depressive disorders or bipolar disorder) compared lithium with placebo for continuation and maintenance treatment that ranged from 20 to 104 weeks; most patients had initially responded to acute treatment with open label lithium . Lithium was prescribed either as monotherapy or as augmentation with pharmacotherapy (eg, antidepressants) and/or psychotherapy, and target serum lithium concentrations ranged from 0.5 to 1.0 mEq/L [0.5 to 1.0 mmol/L]. The findings included the following:
●Lithium was more effective than placebo in reducing the risk of suicide (six suicides occurred, all in patients who received placebo; odds ratio 0.13, 95% CI 0.03-0.66).
●In the subgroup of patients with unipolar depressive disorders (three trials, 280 patients), the number of suicides was less with lithium than placebo (five suicides occurred in patients treated with placebo; odds ratio 0.13, 95% CI 0.02-0.76)
●In the subgroup of patients with bipolar disorder (one trial, 205 patients), the risk of suicide in patients treated with lithium or placebo was comparable. However, only one suicide occurred (in a patient who received placebo), which was too few events to detect a difference.
A prior meta-analysis also found that maintenance treatment with lithium was beneficial for preventing suicide in patients with mood disorders . The analysis (seven randomized trials, 1104 patients, duration of treatment 76 to 128 weeks) compared lithium with other compounds (amitriptyline, carbamazepine, lamotrigine, or placebo). Suicide occurred in fewer patients treated with lithium than other compounds (2 versus 11 patients; odds ratio 0.3, 95% CI 0.1-0.8). In addition, all-cause mortality was also less likely with lithium than other compounds.
Although it is not known how lithium reduces the risk of suicide, lithium can prevent recurrence of mood episodes, and may also reduce aggression or impulsivity [98,100]. The efficacy of lithium in forestalling mood episodes is discussed separately. (See "Unipolar depression in adults: Treatment with lithium", section on 'Lithium monotherapy as maintenance treatment' and "Bipolar disorder in adults: Choosing maintenance treatment", section on 'Lithium'.)
Lithium toxicity and overdose can damage organs and may be lethal. (See "Bipolar disorder in adults and lithium: Pharmacology, administration, and side effects", section on 'Lithium side effects' and "Renal toxicity of lithium" and "Lithium and the thyroid" and "Lithium poisoning".)
Patients with acute major depression who manifest suicidal ideation or behavior are generally treated with antidepressants; low quality evidence suggests that antidepressants may possibly decrease suicides [2,101,102]. As an example, a retrospective registry study found that a doubling of selective serotonin reuptake inhibitor (SSRI) prescriptions was associated with a 25 percent reduction in suicides . Nevertheless, the data supporting the use of antidepressants appear to be less compelling than the evidence for lithium. A meta-analysis of three small randomized trials compared antidepressants (mianserin, nomifensine, or paroxetine) with placebo in 243 patients who were hospitalized after suicide attempts; duration of treatment ranged from 12 weeks to 12 months . Repetition of self-harm was comparable for the two groups. The issue of antidepressants and warnings about increased suicidal ideation and behavior is discussed separately. (See "Effect of antidepressants on suicide risk in adults".)
Tricyclic antidepressants and monoamine oxidase inhibitors may be lethal if taken in high doses; they should be avoided if possible in the depressed patient who has expressed thoughts of suicide . In addition, the serotonin norepinephrine reuptake inhibitor venlafaxine may be dangerous in overdose and should probably be avoided. By contrast, the SSRIs appear to be safer when taken in overdose and should be the drugs of choice in potentially suicidal depressed patients . (See "Tricyclic antidepressant poisoning" and "Acute poisoning from atypical (non-SSRI) antidepressants, including serotonin-norepinephrine reuptake inhibitors (SNRI)", section on 'Venlafaxine' and "Selective serotonin reuptake inhibitor poisoning".)
However, many depressed patients do not respond to initial treatment with an SSRI, and may require pharmacotherapy that includes venlafaxine, tricyclics, or monoamine oxidase inhibitors. Patients with suicidal ideation who are at risk of overdosing on any medication may need to be hospitalized.
Pharmacotherapy for underlying psychiatric disorders in suicidal patients is often nonexistent or inadequate (eg, doses below the therapeutic minimum). Psychologic autopsy studies have found that among all patients who commit suicide, only 8 to 17 percent received any psychiatric medications; among depressed suicide victims, only 6 to 14 percent were adequately treated .
Investigational approaches — Ketamine is a standard anesthetic drug that has been studied as a possible treatment for acute suicidal ideation in the emergency room setting. Information about the investigational use of ketamine for suicidality as well as refractory depression is discussed separately. (See "Unipolar depression in adults: Management of highly resistant (refractory) depression", section on 'Ketamine'.)
Buprenorphine, which is used for opioid use disorder and is potentially addictive and possibly lethal, is another experimental treatment for severe suicidal ideation. A four-week randomized trial compared adjunctive, low dose buprenorphine (mean dose 0.4 mg/day) with placebo in patients (n = 62) with severe suicidal ideation . Patients carried various diagnoses, such as borderline personality disorder, unipolar major depression, and/or adjustment disorder, and were treated with a variety of medications (eg, antidepressants and/or benzodiazepines). Improvement of suicidal ideation was greater with buprenorphine and was independent of treatment with antidepressants. Adverse effects were also more common with buprenorphine than placebo, including fatigue, nausea, dry mouth, and constipation; however, discontinuation of treatment due to side effects was comparable for the two groups. The study medication was abruptly stopped after four weeks; at the follow-up appointment one week later, all of the patients denied withdrawal symptoms and no exacerbation of suicidal ideation was reported.
Psychotherapy — After a suicide attempt, psychotherapy may prevent subsequent attempts. As an example, a national registry study identified patients who attempted suicide and subsequently received either psychotherapy (n >5000) or standard care (n >17,000) . Propensity scoring was used to match the two groups with regard to 31 potential confounders (eg, sex, psychiatric diagnoses, and prior deliberate self-harm). Psychotherapy consisted of 8 to 10 individual sessions focused upon suicide prevention, but was otherwise not standardized; different approaches were used, including cognitive-behavioral therapy (CBT), problem solving therapy, dialectical behavior therapy, or psychodynamic psychotherapy. During 20 years of follow-up, suicide deaths occurred in fewer patients who received psychotherapy than standard care (1.6 versus 2.2 percent). All-cause mortality was also lower in patients who received psychotherapy than standard care (6.9 versus 9.6 percent).
Among psychotherapies, we prefer CBT or problem solving therapy, based upon randomized trials. As an example, a meta-analysis of 10 trials compared CBT or problem solving therapy with usual care in patients (n >2200) with an episode of self-harm, who were followed for up to 12 months . Self-harm included any nonfatal act of self-injury, regardless of suicidal intent. Repetition of self-harm was less likely to occur with CBT/problem solving therapy than usual care (odds ratio 0.80, 95% CI 0.65-0.98). In addition, improvement of depression, including hopelessness and suicidal ideation, was greater with active treatment.
Self-harm includes both nonsuicidal self-injury and suicide attempts, which differ in multiple ways, including frequency; nonsuicidal self-injury may occur daily, whereas suicide attempts occur less frequently . Randomized trials indicate that CBT can specifically reduce suicide attempts. As an example, a randomized trial compared usual care plus CBT (10 weekly sessions) with usual care alone in 120 patients who were evaluated in an emergency department following a suicide attempt; patients were followed for up to 18 months following the baseline interview. Suicide attempts during follow-up occurred in fewer patients treated with CBT plus usual care than usual care alone (24 versus 42 percent) .
If CBT or problem solving therapy are not available, it is reasonable to use other types of other psychotherapies. As an example, a meta-analysis of three randomized trials compared dialectical behavior therapy with usual care in patients (n = 292) with an episode of self-harm, and found that the frequency of self-harm decreased more with dialectical behavior therapy .
Electroconvulsive therapy — For severely depressed suicidal patients, electroconvulsive therapy frequently provides a rapid response that may be lifesaving in the short term, and perhaps in the long term as well. (See "Unipolar major depression in adults: Indications for and efficacy of electroconvulsive therapy (ECT)", section on 'Suicidality' and "Overview of electroconvulsive therapy (ECT) for adults", section on 'Continuation and maintenance ECT'.)
Adjunctive interventions — Adjunctive interventions that address social isolation, and provide a bridge between an emergency department visit and outpatient care, may help reduce suicide attempts. As an example, a prospective observational study compared the benefit of usual care alone (n = 497); universal screening for suicidal ideation or behavior plus usual care (n = 377); and universal screening, usual care, plus an adjunctive intervention (n = 502) in patients who presented to an emergency department and confirmed the presence of active suicidal ideation or a suicide attempt in the past week . The intervention included formulating a self-administered safety plan during the emergency department visit, and seven subsequent telephone calls (each lasting 10 to 20 minutes) focused upon coping with risk factors, personal goals, safety planning, and treatment adherence. Patients were followed for up to one year, during which the risk of suicide attempts was less in patients who received the adjunctive intervention, compared with usual care alone (hazard ratio 0.73, 95% CI 0.55-0.97). By contrast, the number of suicide attempts was similar for universal screening plus usual care compared with usual care alone. Other interventions with demonstrated success for postcrisis suicide prevention include periodically sending letters to patients .
Monitoring and follow-up — Patients at risk of suicide should be followed regularly as warranted by the level of risk, bearing in mind that risk fluctuates, particularly if the patient's situation changes. As part of monitoring previously suicidal patients, the clinician should determine if there have been changes, especially a reemergence of precipitating events, adverse life circumstances, or mental disorders. Following acute management of suicidality, the primary care clinician should assure that patients are actively engaged in ongoing care for any mental disorders and that they receive maintenance treatment to prevent or forestall recurrent episodes of unipolar depression, bipolar disorder, anxiety disorders, psychotic disorders, and substance use disorders.
The risk of suicide is increased in the days and initial weeks following discharge from psychiatric hospitalization, particularly if patients perceive that they have lost a therapeutic support system, including contact with a mental health professional. The risk is particularly high in the first week after discharge , and more than one-third of all suicides in the first year following hospital discharge occur in the first month .
Scheduling the first follow-up visit soon after a psychiatric hospitalization may reduce suicide rates. An observational study found that implementing a policy to follow-up patients within seven days of discharge was associated with a decreased rate of suicide during the three months after discharge (from 2.5 to 2.0 suicides per 10,000 discharged patients) .
Patients are also at high risk for nonadherence to pharmacotherapy soon after discharge, and thus have a consequent increased risk of suicide. By contrast, those who continue care in the community and who maintain pharmacotherapy are at lower risk . In addition, an observational study found that assertive community outreach to patients who are nonadherent with medications or appointments was associated with decreased suicide rates . Nonadherence may be due to adverse effects, lack of symptom relief, not understanding the purpose of medications, or failure to appreciate the consequences.
POSTSUICIDE INTERVENTION — Postsuicide interventions are intended to help family, friends, or coworkers understand why suicide victims killed themselves, and decrease the assumption of inappropriate guilt for the death. The intervention is often designed to identify those at risk of suicide, as well as prevent posttraumatic stress disorder, complicated grief, and depressive syndromes.
However, there is little evidence that postsuicide interventions are beneficial. As an example, a randomized trial compared psychoeducation (four sessions, each lasting two hours, administered during home visits) with no intervention in 83 individuals bereaved through suicide; improvement of depressive symptoms (including suicidal ideation) and complicated grief symptoms in the two groups was comparable . Nevertheless, monitoring for posttraumatic stress disorder, complicated grief, depression, and suicide risk factors may be beneficial.
SUMMARY AND RECOMMENDATIONS
●Major risk factors for suicide include psychiatric disorders, hopelessness, and prior suicide attempts or threats. High impulsivity and alcohol or other substance abuse increases the risk that suicidal impulses will be carried out. (See 'Risk factors' above.)
●Although concerns have been raised that antidepressants are associated with an increased risk of suicide, the risk of antidepressant-related suicidality must be weighed against the benefits of treatment and the long-term risk of suicide in untreated depression. (See "Effect of antidepressants on suicide risk in adults".)
●Patients suspected to be at risk for suicide should be asked about suicidal ideation and intent, and, if present, the lethality of the plan should be evaluated. The evaluation should include discussion of a safety plan (figure 1). (See 'Patient evaluation' above.)
●Patients at risk for suicide require psychiatric services and monitoring to ensure safety. The level of care is determined by the evaluation; options typically include inpatient hospitalization, partial hospital, intensive outpatient program, and outpatient clinic (algorithm 1). (See 'Management' above.)
●After immediate safety has been ensured, underlying factors of psychiatric disorders, precipitating events, and ongoing life circumstances should be addressed with medications, counseling, and involvement of friends, family, and religious/community groups as appropriate. (See 'Underlying factors and mental disorders' above.)
●For patients with bipolar and depressive disorders who remain at risk for suicide following immediate and short-term stabilization with treatment that includes lithium, we suggest continuation and maintenance treatment with lithium as monotherapy or as adjunctive treatment with other medications and/or psychotherapy, rather than discontinuing lithium (Grade 2B). (See 'Pharmacotherapy' above.)
●After a suicide attempt, psychotherapy (eg, cognitive-behavioral therapy) may prevent subsequent attempts. (See 'Psychotherapy' above.)
●Patients are at increased risk for suicide soon after discharge from psychiatric inpatient care. (See 'Monitoring and follow-up' above.)
●Patients with a history of suicidality should be monitored closely in follow-up and assessed for the recurrence of symptoms or risk factors. (See 'Monitoring and follow-up' above.)
●After a suicide, friends, family, and coworkers may be at increased risk for suicide and for posttraumatic stress disorder and depression, and may benefit from monitoring for appropriate grieving. However, there is little evidence that postsuicide interventions are beneficial. (See 'Postsuicide intervention' above.)
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