▲ 32.1 Suicide: Overview and Epidemiology DANUTA WASSERMAN, M.D.

INTRODUCTION The problem of suicide cannot be limited to just one discipline,

and the complexity of self-destruction transcends the psychiatric field. Suicide can
be viewed from many perspectives like religious, philosophical, anthropological,
sociological, ethical, psychological, and psychiatric/biological. In suicide
prevention, strategies can be directed toward health care services or at the
general population. The health care strategy aims at identifying risk groups,
improving diagnostics, treatment, and offering better rehabilitation for suicidal
patients. Health care interventions can be selective and target subgroups
displaying risk factors for suicide, or indicated, that is, targeting individuals with
identified psychiatric disorders, who have severe suicidal ideation or have
attempted suicide. The public health approach comprises strategies that aim to
increase awareness about the role of protective factors for mental health,
attitudes toward the mentally ill or suicidal persons, and promote measures to
eliminate fears and misunderstandings that surround suicide. Protective factors
for suicide include cognitive flexibility, active coping strategies in difficult life
situations, healthy lifestyles, active social networks, confidence and the sense of
personal value, and the ability to seek advice from others and help from the
health care system for subsequent treatment. It comprises also strategies for
promoting mental health, social welfare, and education policies. This chapter
focuses on the broad spectrum of psychopathology in suicidality, and on
treatment and preventive interventions used in the health care and public health
sectors. Universal public health interventions like restricting lethal means to
suicide and school-based interventions are also shortly described.

EPIDEMIOLOGY

Suicide The WHO report “Preventing suicide: a global imperative” published in

2014 estimates that over 800,000 people die by suicide, and more than 20 million
attempt suicide each year. This implies that every 40 seconds, a person dies by
suicide somewhere on the globe, and every 1.5 seconds, someone will attempt to
take his/her own life. However, those numbers are underreported, as not all
countries in the world report suicide mortality to the WHO. Only 59 out of 194
Member States have good quality mortality registration data. Furthermore, in
countries with good mortality statistics, suicides can be misclassified as accidents,
homicides, or unknown causes of death. Annual global suicide rates are 15 for
males, 8 for females, and 11.4 per 100,000 population. Globally, suicides account
for 52 percent of all violent deaths in men and 71 percent of all violent deaths in
women. In high-income countries, 79 percent of violent deaths in both males and
females are caused by suicide. Suicide occurs in all regions of the world and
throughout the life span, and it accounts for 1.4 percent of all deaths worldwide,
by that, ranking as the 15th leading cause of death. Among young people 15 to 29
years of age, suicide is the second leading cause of death globally after traffic
accidents and accounts for 8.5 percent of all deaths. Tables 32.1–1 and 32.1–2
show the number and suicide rates by age group in all WHO regions for males and
females, respectively. Suicide rates for males are highest in Europe, followed by
Southeast Asia and Western Pacific. Suicide rates for females are highest in
Southeast Asia and Western Pacific. In Table 32.1–3, the absolute numbers,
crude, and age-adjusted suicide rates per 100,000 persons in each state in the
United States are shown. The age-adjusted suicide rate for the United States is
12.6 per 100,000 population. The highest age-adjusted suicide rates are in
Montana, Alaska, Wyoming, Utah, New Mexico, Idaho, Colorado, Nevada, South
Dakota, while the lowest are in the District of Columbia, New Jersey, New York,
Massachusetts, and Connecticut. Within the same region, suicide rates can vary
from one district to another. Therefore, it is important for tailored suicide
prevention to survey local data from both population and clinical settings, as risk
groups and risk factors can vary considerably at the local level. Socio-
Demographic Factors In low- and middle-income countries, the male-to-female
ratio of agestandardized suicide rates is approximately 1:6 in comparison with
high- income countries, where the ratio is 3:5. Differences between genders in
coping with stress and conflicts, patterns of alcohol consumption and helpseeking
behaviors for mental disorders, as well as access to lethal methods to suicide can
explain regional and gender differences. Suicide rates are highest both for males
and females in persons aged 70 years and older in nearly all regions of the world.
Young adults and elderly women have, however, much higher suicide rates in low-
and middleincome countries than in high-income countries. The opposite has
been found among middle-aged men in high-income countries, who show a much
higher suicide rate than middle-aged men in low- to middle-income countries.
Status of being unmarried, divorced, widowed, elderly, unemployed, immigrant,
and having different sexual orientation are risk factors increasing the propensity
for suicide. Moreover, individuals in the armed forces, veterans, prisoners, and
indigenous people have an increased risk of suicide. Since Durkheim, religion,
marriage, and parental responsibilities are known key factors that play a crucial
role in controlling suicide impulses. Moreover, the impact of values, social
political trends, societal patterns of drug and alcohol use, and violence is also of
great relevance. Table 32.1–1. Estimated Numbers and Rates of Suicide by Age
Group for Men in WHO Regions a WHO Region 0–4 5–14 15–29 30–44 45–59 60–
69 70–79 80+ Total Numbers World 0 5,961 136,532 128,196 117,916 52,222
43,984 21,676 506,487 Africa 0 724 11,422 9,603 6,939 3,580 2,251 903 35,423
Americas 0 571 15,171 15,127 13,936 5,309 3,478 2,635 56,227 Eastern Medit. 0
548 6,753 4,585 2,787 981 896 681 17,230 Europe 0 509 19,635 25,842 28,615
10,480 9,329 5,070 99,480 SE Asia 0 2,502 64,548 49,869 33,048 9,965 6,776
2,052 168,761 Western Pacific 0 1,107 19,002 23,170 32,590 21,907 21,254
10,335 129,366 Rate per 100,000 World 0 0.9 15.3 17.8 23.4 28.2 42.2 60.1 14.9
Africa 0 0.7 10 15.1 20.9 30.7 43 77.5 8.8 Americas 0 0.7 13.4 15.9 18.9 18.9 22.2
34.1 12.4 Eastern Medit. 0 0.8 7.6 8.1 8.8 9.5 17 44.7 5.8 Europe 0 1 19.9 26.8
33.6 29.2 37.9 53.2 23.1 SE Asia 0 1.4 25.6 26.8 27.5 25.6 35.8 40.4 18.8 Western
Pacific 0 0.8 8.5 10.4 20.4 36.5 61.6 93.5 14.1 aVärnik P. Suicide in the world. Int J
Environ Res Public Health. 2012;9(3):760–771. Methods of Suicide National level
data on suicide methods are limited, as many countries do not collect this
information. Only 76 out of the 194 WHO Member States reported data on
methods of suicide in 2012. The coverage rate is much better in high-income
countries than in low- and middle-income countries. Hanging accounts for 50
percent of all suicides in high-income countries, while firearms account for 18
percent. Suicide methods and rates, however, vary between regions. In the
Americas, for example, firearms account for 46 percent of all suicides, in
comparison with other high-income countries where firearms account for only 4.5
percent of all suicides. It is estimated that self-poisonings with pesticides are
responsible for approximately 30 percent of global suicides in low- and middle-
income countries. In some countries in Asia, jumping from high buildings is a
common method of suicide. Since 1998, the use of barbeque charcoal, which
produces the highly toxic carbon monoxide gas, as a means for suicide has spread
rapidly in many Asian countries. Suicide Trends The global age-standardized
suicide rate has fallen 23 percent in males and 32 percent in females from 2000 to
2012. The reasons for such positive change can be many. One likely explanation
could be the improvement of global health due to the awareness of the problem
and widespread use of new treatment methods. Attempted Suicide There is a lack
of systematic registration of attempted suicides across national levels. Data on
suicide attempts typically derive from self-reported surveys in the general
population, or from hospital-based data of medically treated suicide attempts.
Table 32.1–2. Estimated Numbers and Rates of Suicide by Age Group for Women
in WHO Regions a WHO Region 0–4 5–14 15–29 30–44 45–59 60–69 70–79 80+
Total Numbers World 0 5,764 94,959 60,378 48,413 24,791 24,077 17,145
275,527 Africa 0 354 6,303 2,273 2,775 1,974 1,452 778 15,909 Americas 0 409
4,311 4,124 4,517 1,378 638 460 15,837 Eastern Medit. 0 555 8,124 3,443 1,776
410 444 353 15,104 Europe 0 203 4,001 5,228 7,017 3,464 3,559 2,924 26,395 SE
Asia 0 3,413 59,109 23,793 10,378 5,284 2,635 1,070 105,683 Western Pacific 0
830 13,112 21,517 21,950 12,282 15,349 11,560 96,599 Rate per 100,000 World 0
1 11.2 8.6 9.5 12.4 18.7 27.8 8.2 Africa 0 0.3 5.5 3.6 7.7 14.7 22.3 44.5 3.9
Americas 0 0.5 3.9 4.3 5.8 4.4 3.3 3.5 3.4 Eastern Medit. 0 0.9 9.6 6.6 6 3.9 8 21.1
5.3 Europe 0 0.4 4.2 5.4 7.7 8.1 9.9 14 5.8 SE Asia 0 2 25 13.4 8.9 12.6 11.7 16.6
12.3 Western Pacific 0 0.7 6.3 10.1 14.1 20.5 39.5 64.7 11.1 aVärnik P. Suicide in
the world. Int J Environ Res Public Health. 2012;9(3):760–771. Table 32.1–3.
Number, Crude, and Age-Adjusted Suicide Rates per 100,000 of Population in
Each State of USA for All Ages and Both Genders, 2013 (Ranked by the Age-
Adjusted Suicide Rate) State Number Crude Rate Age-Adjusted Rate Rank United
States 41,149 13.0 12.6 Montana 243 23.9 23.7 1 Alaska 171 23.3 23.2 2 Wyoming
129 22.1 21.5 3 Utah 579 20.0 21.4 4 New Mexico 431 20.7 20.3 5 Idaho 308 19.1
19.2 6 Colorado 1,007 19.1 18.6 7 Nevada 541 19.4 18.6 8 South Dakota 147 17.4
18.0 9 Arizona 1,163 17.6 17.5 10 Maine 245 18.4 17.4 11 Arkansas 516 17.4 17.3
12 North Dakota 128 17.7 17.3 13 Oklahoma 665 17.3 17.2 14 Oregon 698 17.8
16.8 15 Vermont 112 17.9 16.8 16 West Virginia 323 17.4 16.4 17 Missouri 960
15.9 15.6 18 Kentucky 701 15.9 15.5 19 Tennessee 1,030 15.9 15.4 20 Kansas 425
14.7 14.7 21 Alabama 721 14.9 14.4 22 Iowa 447 14.5 14.4 23 Wisconsin 850 14.8
14.4 24 Indiana 944 14.4 14.2 25 South Carolina 696 14.6 14.0 26 Washington
1,027 14.7 14.0 27 Florida 2,928 15.0 13.8 28 Pennsylvania 1,788 14.0 13.4 29
Mississippi 388 13.0 13.0 30 Michigan 1,295 13.1 12.9 31 Ohio 1,526 13.2 12.9 32
New Hampshire 185 14.0 12.8 33 North Carolina 1,284 13.0 12.6 34 Delaware 122
13.2 12.5 35 Virginia 1,072 13.0 12.5 36 Louisiana 583 12.6 12.4 37 Rhode Island
132 12.6 12.2 38 Minnesota 678 12.5 12.1 39 Georgia 1,212 12.1 12.0 40 Hawaii
171 12.2 11.8 41 Texas 3,059 11.6 11.7 42 Nebraska 220 11.8 11.6 43 California
4,025 10.5 10.2 44 Illinois 1,321 10.3 9.9 45 Maryland 569 9.6 9.2 46 Connecticut
330 9.2 8.7 47 Massachusetts 572 8.5 8.2 48 New York 1,687 8.6 8.1 49 New
Jersey 757 8.5 8.0 50 District of Columbia 38 5.9 5.7 51 Murphy SL, Xu J, Kochanek
KD. Deaths: Final Data for 2010. Division of Vital Statistics, Centers for Disease
Control and Prevention. USA; 2013. Based on national surveys from 10 high-
income, 6 middle-income, and 5 low-income countries, the 1-year prevalence of
having made one or more suicide attempts in the year prior is estimated to be 4.1
per 1,000 adults. In relation to the estimated 2012 global suicide rate of 15.4 per
100,000 adults aged 18 years and over, the global estimate in the WHO 2014
report is that for each adult who committed suicide there were 27 persons who
made one or more suicide attempts. There is a wide variation in the attempt-
tosuicide death ratio with respect to age, sex, region, and methods used. Suicide
attempts are known to be the single most important risk factor for completed
suicide. In spite of this, there are very few countries that contain registries of
medically treated suicide attempters. In clinical work, the presumed continuum
from suicidal ideation through suicide attempts to suicide completions can be a
helpful model in understanding the suicidal process, risk detection, and treatment
choices, even if this model cannot be applied to all suicides.

PSYCHIATRIC DISORDERS AND SUICIDE

Risk factors for suicide are both individual and familial. Suicidal behaviors
aggregate in families, and family history of suicidal behaviors is an independent
risk factor for suicide attempts and completed suicides. The presence of current
and lifetime psychiatric diagnoses like major depressive disorder (MDD), bipolar
disorders, anxiety disorders, alcohol and substance misuse, schizophrenia, eating
disorders, personality disorders, different types of trauma, chronic somatic
disorders, and current stressful life events are significant risk factors for suicidal
behaviors. In the context of suicide, there is a growing body of evidence showing
that exposure to early-life maltreatment can affect molecular mechanisms
involved in the regulation of behavior through methylation and histone
modification, supposed to induce behavioral deviations during the early
development, and possibly later in life, affect genes involved in crucial neural
processes. This mechanism is called epigenetics. Childhood abuse and other
detrimental environmental factors seem to target the epigenetic regulation of
genes involved in the synthesis of neurotrophic factors and neurotransmission.
MDD is strongly linked with suicide, especially if long-term comorbidity and acute
negative life events are present. The clinical picture is characterized by symptoms
like weight loss or gain, sleep disturbances, fatigue, concentration difficulties,
changes in psychomotor capabilities, feelings of worthlessness, guilt, and
recurrent thoughts of severe suicidal ideation with suicidal plans. In the
melancholic type of MDD, despondency, despair, irrational guilt, and emptiness
are profound symptoms. Patients diagnosed with dysthymia (persistent
depressive disorder) complain of irrational patterns of negative thinking and
chronic dysphoria. Depressed suicidal patients have similar risk factors for suicide
as patients with other psychiatric diagnosis, namely, living alone, being
unmarried, unemployed, and a history of previous suicide attempts. Recurrent
MDDs are robust precipitants of suicidal behaviors. Physical illnesses also increase
the risk of suicide and attempted suicide in depressed patients, especially in the
elderly population. The most common comorbidity for affective disorders in
suicidal behavior is alcohol and other substance use, multiple physical
impairments, and personality disorders. Independently of the direction
concerning the link between different forms of depression and comorbidity, it is
important from the clinical point of view to treat all disorders. The risk of suicide
varies between the different subtypes of depression. Affective temperaments like
cyclothymic disorder and anxiousness are associated with both suicide attempts
and suicide. Such temperaments, along with irritability and rapid mood switches,
are important contributors in triggering suicidal acts. Bipolar Disorders Bipolar
disorders are separated from other depressive disorders in the DSM-5
classification and are placed between the diagnostic class on depressive disorders
and schizophrenia/other psychotic disorders, in order to denote a bridge between
those two diagnostic classes with respect to symptoms, family history of
psychiatric disorders, and molecular genetic findings. Bipolar disorders constitute
a high-risk group for suicide and attempted suicide. The majority of persons with
bipolar disorders commit suicide when they are in a major depressive episode or
in a mixed depressive state. Suicide during the manic phase is rare. The
prevalence of suicide attempts is similar in both type I and type II bipolar
disorders. Comorbidity of substance use disorders, depression, and anxiety is
almost always present in persons who committed suicide. Effective
pharmacological treatment supported by psychological techniques is the
foremost strategy to prevent completed suicide. Alcohol and Substance Use
Disorders Excessive alcohol and other substance misuse leading to significant
impairment and distress are well-recognized conditions for an increased risk of
suicidal behaviors. Comorbidity with personality disorders magnifies the risk of
suicide. Suicide mortality is highest among drug users and lower, but still high,
among persons with alcohol use disorders, as well as more prevalent among
males compared to females. Alcohol and other substance misuse increase
aggressivity, impulsivity, and cause deterioration in cognitive capacity and
flexibility to find constructive coping strategies. Suicidal alcohol misusers,
however, have a fairly good psychosocial coping ability, which could make their
suicide appear more astounding. Good psychosocial functioning could potentially
explain why they did not seek treatment or receive attention from significant
others to motivate them for treatment. Triggers for suicidal behaviors in persons
with alcohol and substance use disorders are losses of important relationships,
work, economical security, and self-esteem. The more dependence the substance
users’ experience in their relationships, the greater the risk that separation may
push them into self-destructive acts. Guidelines for the treatment of alcohol and
substance misuse are published by the American Psychiatric Association (APA)
and by the National Institute for Health and Care Excellence (NICE). The duration
of treatment may vary, but it is important to use both pharmacological and
psychological treatments. Decreasing the accessibility to alcohol both on a
societal and individual level, as well as moulding attitudes toward alcohol intake
show significant results in diminishing suicide, as described during the Perestroika
period in the former USSR. Anxiety Disorders Anxiety as a risk factor for suicide
has been neglected for a long time, that is, until studies by Fawcett et al. put
forward the role of severe anxiety in precipitation of suicidal behaviors. There are
many ways to assess the severity of anxiety, and it is important that suicidal
psychiatric patients, especially those with mood disorders, substance use
disorders, and in psychotic states are assessed for the presence of severe anxiety
and treated for it. Patients who suffer from severe anxiety may sometimes deny
suicidal thoughts or suicidal intent and refuse hospitalization. It is recommended
to document in the medical journal, the patient’s decision and secure that
outpatient treatment includes frequent follow-up and, whenever possible, involve
the family. Schizophrenia and Other Psychotic Disorders In the schizophrenic
population, estimates show that approximately 5 to 10 percent die due to suicide.
Already Bleuler drew clinicians’ attention that the most serious of the
schizophrenic symptoms is the suicidal drive. Moderate-to-severe depression is
one of the most frequent features of schizophrenic patients who commit suicide.
Schizophrenics who commit suicide usually have poorer treatment compliance,
not seldom due to the side effects of antipsychotic medication like akathisia.
Suicides occur after abrupt discontinuation of medication. Negative attitudes
toward medication and treatment are generally high in both schizophrenic and
suicidal patients with other psychiatric diagnosis. Poor treatment compliance,
social isolation, and increased expectation of good performance from others and
from patients themselves, are risk factors for suicide in schizophrenics. For a long
time, there has been controversy surrounding the question whether
schizophrenics commit suicide during the intense and frightening psychotic
activity or during periods of remission. Studies found that command
hallucinations are rare among completed suicides. On the contrary, a good
premorbid functioning and higher level of education may predispose to suicide in
younger schizophrenic patients, as they experience more disruption of
performance and may have more difficulty to accept chronic illness and prospects
of mental deterioration than older schizophrenic patients. When giving
information about the diagnosis, course of illness, and treatment, one should be
aware that it is a risk situation for suicide. Eating and Adjustment Disorders
Patients with anorexia nervosa have an increased suicide risk, thus suicide risk
assessment should be included in a comprehensive clinical evaluation. Patients
with bulimia nervosa and binge eating disorders also have an increased risk of
suicidal behaviors. A high comorbidity of mental illnesses like MDD, bipolar
disorder, anxiety disorders, and borderline personality disorders (BPDs) among
persons who are underweight as well as overweight is to a great extent
responsible for the high suicide risk in all eating disorders. Treatment is often
complicated and requires behavioral therapy combined with medication and
supportive measures. Low body mass index (BMI) and low serum cholesterol have
been shown to be associated with a higher risk of attempted and completed
suicide. Prevention Organizing home visits, case management, and regular
telephone contacts with somatically ill and vulnerable elderly persons are
effective preventive methods, as it diminishes isolation and provides the
opportunity to early detect risk factors and risk situations for suicide.

PERSONALITY DISORDERS AND SUICIDE

Personality disorders have been previously understudied in clinical and

population studies on suicidal behaviors. In 894 cases of suicide among young
people, 11 percent received personality diagnosis, mainly antisocial and
borderline. The remaining diagnoses were paranoid, narcissistic, anxious, and
histrionic personality disorders. This low percentage depends on, among other
factors, the difficulties of retrospective diagnostics of personality disorders.
Persons diagnosed with Cluster B comprising borderline, antisocial, histrionic, and
narcissistic personality disorders are characterized by poor impulse control,
aggressivity, unstable identity, poor self-image, affective instability with
proneness to experience and strongly react to real or imagined environmental
stresses and losses. Difficulties with interpersonal relationships, problem solving,
and inability to plan and think about the future in positive terms increase the
propensity for triggering suicidal behaviors. Cluster C personality disorders, which
include avoidant and obsessive compulsive disorders, are not strongly associated
with suicide. Only dependent personality disorder in the Cluster C is significantly
associated with suicide attempt, but this association is likely due to the
comorbidity of lifetime and concurrent depressive disorders. Among Cluster A
personality disorders, mainly schizoid personality disorder has been shown to
increase the risk of suicide. Schizoid personality disorder is quite rare, both in the
general and clinical populations, and therefore, it is difficult to estimate a true
prevalence and association with suicidal behaviors. Personality disorders
contribute even more to the risk of suicidality when comorbid with other
psychiatric diagnosis, and in the presence of negative life events, especially those
involving interpersonal distress and loss. Concurrence of psychiatric disorders
with personality disorders is now recognized as a major factor in suicide and in
attempted suicide.

SOMATIC DISORDERS AND SUICIDE

Studies performed in the United States, Australia, and Europe show an association
between suicidal behaviors and chronic somatic disorders. Somatic disorders
involve physical, psychological, and social implications. They imply stress, pain,
sometimes handicaps, limited social performance, decrease in the capability to
work, and the increased need for help from others. The comorbidity of somatic
disorders with psychiatric disorders, especially with MDD and personality
disorders substantially increases the risk for suicide. Age and separation from
loved ones, loneliness, hopelessness, helplessness, and social isolation are
parameters of importance for suicide risk. The suicidal situation and the suicidal
propensity vary during the course of the somatic disorder and depend on the
treatment outcomes and pain control, as well as on psychosocial comfort. Cancer,
HIV infection and AIDS, stroke, diabetes mellitus, epilepsy, Parkinson disease,
trauma with subsequent brain damage, spinal cord injury, multiple sclerosis,
Huntington disease (HD), and amyotrophic lateral sclerosis are associated with an
elevated risk of suicide. Elderly patients with chronic or incurable diseases need to
have an adequate somatic and psychiatric treatment, as well as good psychosocial
care in times of shrinking economical resources. Different opinions on the
distribution of economical resources can sometimes be associated with advocacy
concerning euthanasia and assisted suicide.
SPECIAL POPULATIONS Children and Adolescents Poor Mental Health. Mental ill-
health is the leading cause of disability in young persons aged 10 to 24 years and
is responsible for 45 percent of the overall burden of disease in this age group.
The high prevalence of mental health disorders was shown in the Great Smoky
Mountains prospective cohort study in the United States, as well as in the
National Comorbidity Survey, also in the United States. The results of the Saving
and Empowering Young Lives in Europe (SEYLE) study showed that in a usual
school class of teenagers approximately 10 percent of young people display high-
risk behaviors like excessive alcohol and illegal drug use, heavy smoking, truancy,
etc. Thirty percent display unhealthy lifestyles like poor sleep and diet, physical
inactivity, excessive Internet/media use. Both of those groups have high levels of
depression, anxiety, and suicidal behaviors. Approximately 12.5 percent of
adolescents required qualified psychiatric and psychological help. However,
experiences from the SEYLE study in Europe and the Columbia University
TeenScreen program in the United States show that there is a fear of stigma when
screening for mental health problems in schools, and both parents and
adolescents show little trust in the mental health care systems. Therefore, the
process of destigmatization of screening for mental disorders and increasing help-
seeking behaviors is an important public health issue. SEYLE results show that
younger adolescents are more likely to adhere to rules, procedures, and
recommendations with higher attendance rates to health care system for girls and
for pupils victimized by peers. Suicidal behaviors also appear to be an important
predictor for help seeking and a predictor of referral to mental health care. Risk
for Suicide. For most adults, it is difficult to acknowledge the child’s despair and
suicidality. Caretakers as well as parents can deny serious childhood diagnosis due
to guilt feelings and frustrations when they have difficulties to handle a suicidal,
depressed child or a suicidal child with serious conduct difficulties. Suicidal
behavior in children and adolescents occurs in the context of stressful, chaotic,
and often unpredictable family events. Suicidal children and adolescents have
poor self-esteem and poor personal identify, are often truant, not seldom bullied,
and have poor school grades, which leads to a sense of inadequacy. Issues of
gender identity are well recognized as risk factors for adolescent suicides. The
families of these children and adolescents show a high incidence of affective
disorders, alcohol misuse, and other psychiatric diagnosis. The major risk factors
for suicide in young people are the presence of a psychiatric disorder, especially
affective disorder, substance misuse, and BPD. Attempted suicide is an important
risk factor for future suicide. The four comorbid clinical constellations described
by Apter et al. having a special significance for young suicides are; the
combination of schizophrenia, depression, and substance misuse; the
combination of substance misuse, conduct disorder, and depression; the
combination of affective disorder, eating disorder, and anxiety disorders; the
combination of affective disorder, personality disorder of paranoid and schizoid
type, and dissociative disorders characterized by disruption in integrated
functions of consciousness, memory, identity, or perception of the environment.
Treatment. The treatment of suicidal children and adolescents should include the
individual child and the entire family. The aim is to improve coping styles and
communication between parent and child. Psychosocial rehabilitation measures
including school consultation and academic remediation are important. The
treatment of underlying psychiatric disorders requires psychotherapeutic and
pharmacological treatment when deemed necessary. When medication is used in
the management of suicidal young persons, family can get a false sense of
security, as well as the fantasy that the problem has been solved, which lowers
motivation to work through the problems in family and school situation. If child or
adolescent manifests psychosis, then hospitalization is required. Hospitalization is
also necessary in case of alcohol and drug misuse in the context of a disruptive
home situation. If a young person perceives rejection in the family, a replacement
home can be a solution during the period of treatment and rehabilitation. Elderly
Risk Factors. Elderly persons have the highest suicide rate compared to any other
age group. Decreased economical resources after retirement, placement into
long-term care or residential care can increase the risk of suicide. The elderly
suicides are characterized by high lethality methods, social isolation, and the
presence of physical illnesses. The ratio of suicide attempt to suicide is very low
among the elderly, and therefore each suicide attempt in older persons should be
taken seriously, being an important harbinger of completed suicide. Diagnoses of
MDD are the most common in elderly suicides, followed by diagnosis of alcohol
misuse and organic brain syndrome. Changes of sleep pattern, appetite changes,
as well as somatic complaints or exacerbation of chronic concerns, which stop an
elderly person from going out can be a sign of depression. Symptoms of guilt,
sadness, or anhedonia can be masked by somatic expressions. Unconscious
negative attitudes toward the elderly may create a risk of not taking suicidal risk
in older persons seriously. Dementia It is not seldom that cognitive functions are
severely impaired and depression can sometimes be misdiagnosed as dementia.
Evidence shows that suicide risk in people with dementia is low. However, in the
period immediately after diagnosis of dementia, especially in those of younger
age, the suicide risk is high. Treatment The treatment of suicide risk in the elderly
does not differ from suicide treatment in other age groups. In cases of severe
depression, when medication does not help, electroconvulsive therapy (ECT) can
be recommended. In the treatment of the elderly, drug-to-drug interactions are
important to observe, as the elderly often have multiple medications. In talkative
therapy, it can be of value to focus on what the person has accomplished in life,
rather than to talk about what may or may not lie ahead. To discuss suicidal
ideation can be part of a process that puts one’s life into perspective, and by
acknowledging their suicidal thoughts, the clinician can help the patient move
away from the wish to die. Inclusion of family and other resources in the
community should be encouraged in order to diminish loneliness and social
isolation.

SUICIDE RISK ASSESSMENT Decisions regarding the level of suicide risk are made
every day in all clinical specialties, even if suicide is regarded as a psychiatric
domain. There are many obstacles when performing the suicide risk assessment
due to the uniqueness of each individual possessing a unique set of risk factors.
Uncontrollable environmental influences, which contribute to the outcome, are
another obstacle. Clinical Interview In suicide risk assessment, the most important
instrument is clinical inquiry. This inquiry has an impact on the suicidal patients’
communication which should be clear, empathetic, free from prior criticism, and
focus on facts and patients’ emotional and communication style. In a systematic
clinical assessment of suicide risk, the presence of severe anxiety, MDD, use of
alcohol or illicit substances, and previous suicide attempts should be covered. The
presence of suicidal communication and personality type should be scrutinized.
Previous psychiatric disorders, suicide or suicidal behaviors in the family, as well
as negative life events along with feelings of helplessness, hopelessness, sleep
problems, and impulsive behaviors should be examined. Repeated assessments
are recommended to understand the mechanisms that generate the suicidal urge
or impulse. Interview with the family or significant others is an important source
of information. However, permission by the patient must be given and it can
sometimes take time to motivate the suicidal person to involve the family. The
evaluation of the social network and quality of family support should always be
included when suicide risk assessment is done before temporary or final discharge
from the hospital. Psychometric Scales A set of scales can be used to compliment
clinical inquiry. The Suicide Intent Scale (SIS), Scale for Suicidal Ideation (SSI-C),
the Beck Hopelessness Scale, the SAD PERSONS SCALE, and the Columbia Suicide
Severity Rating Scale (C-SSRS) are used for assessing the risk of suicide. Some
biological and genetic markers have been described, but none of them has a
practical application for clinical suicide risk assessment at the present moment.
The final decision in the suicide risk assessment is always based on an intuitive
judgment and therefore the clinician should be aware of feelings toward a suicidal
patient, which can contribute to a denial of suicide risk, a rigid approach to the
patient, or even negative emotional states like ambivalence or hostility. Those
feelings and behaviors are called countertransference.

MANAGEMENT OF THE SUICIDAL PATIENT Hospitalization or Not Following the

assessment of suicide risk, the first important decision to be taken is the choice
between admission of the patient to a psychiatric ward or treatment in outpatient
care. The decision does not depend only on the status of the patient, but also on
the quality of the available family support and the accessibility to qualified
outpatient treatment. Hospitalization is usually not the first option for most
suicidal patients, but in severe cases it provides security, if safety measures at the
psychiatric ward are followed. In the management of the suicidal patient in the
hospital, precautions are important in restricting access to means of suicide in the
ward and establishing different degrees of freedom while maintaining an
empathetic encounter. Suicide in the Ward When a suicide or a suicide attempt
takes place in the psychiatric ward, it is important to give support to all patients.
The regular suicide risk assessment should be carried out for patients judged to
be at risk. In addition to the usual treatment, an intensive psychosocial support
should be given, to work through the emotions and the possible identifications
with the patient who committed suicide at the same or neighboring unit. Also, the
personnel at the ward should be given psychological support. Treatment of Acute
Suicidal Crisis In the treatment of the acute suicidal crisis, it is important to focus
on reducing anxiety, insomnia, depression, and psychotic symptoms.
Collaboration with the family and significant others must be secured. Safety
measures should also be considered in the home environment and family
members should be alerted of the increased risk of suicide after discharge from
the hospital. The plan for follow-up treatment and establishing collaboration with
rehabilitation units and community services for chronically suicidal patients,
especially those with the diagnosis of substance misuse, schizophrenia, or other
psychotic disorders is recommended. Finally, it is important to have a proper
documentation about communication between different departments, family,
social services, and have a clear follow-up plan. The patient and the family should
also be informed that they need to seek psychiatric emergency services as soon as
a new suicidal crisis arises.

PHARMACOTHERAPY Mood-Stabilizing Treatments Lithium. Meta-analyses,

reviews, and original studies show that longterm lithium treatment is associated
with a substantial reduction of the risk for suicide and attempted suicide in
patients with bipolar spectrum disorders. The analyses by the US Center for
Disease Control and Prevention (CDC) show that mortality by overdoses of lithium
is similar to the mortality from overdoses of new antidepressants and
antipsychotic agents. Ecological studies also show that lower rates of suicide as
well as other violent behavior are found in populations exposed to drinking water
with relatively high concentration of lithium salts. There is no plausible
explanation for this finding as the daily intake of lithium in the drinking water is
much lower than dosages required for clinically effective treatment of mood
disorders. Other Mood Stabilizers. In bipolar depression, other mood stabilizers,
such as anticonvulsants or second-generation antipsychotics have beneficial
effects on suicidal behavior. However, lithium is noted to be significantly superior
in reducing suicidal behaviors. Antidepressants. Selective serotonin reuptake
inhibitors (SSRIs) are nowadays widely used in the treatment of suicidal patients
with MDD and related conditions. When choosing an antidepressant for a suicidal
depressive patient, compounds with a sedative profile are preferable.
Medications that increase drive may increase the risk of suicide. Adverse
outcomes in some patients during treatment with SSRI antidepressants like
agitation, restlessness, irritability, dysphoria, anger and insomnia can worsen the
suicide risk in these patients. Due to those responses to serotonergic
antidepressants, especially in some children and young adults below the age of 25
years, the Food and Drug Administration (FDA) and the European Medicine
Agency (EMA) recommend continuous and competent monitoring of side effects.
Antidepressants may also increase suicide risk in bipolar patients.
Electroconvulsive Therapy. Cases of depression with suicidality, which are difficult
to treat by other means, can be treated by ECT, which has a rapid onset of action
and relief of symptoms. Antipsychotics. Suicidal symptoms in schizophrenic
patients require, in addition to the standard treatment of the schizophrenia with
antipsychotics, an additional medication to control anxiety or agitation. Sedating
antipsychotics are mostly used in these cases. When high dosages are required,
attention must be paid to the risk of acute hypotension with tendency to collapse
when standing up. In some cases, to better control anxiety, benzodiazepines can
be administered for a short period of time. In the case of post-psychotic
depression, an additional treatment with antidepressants is recommended. If the
suicidal symptoms are part of a depressive syndrome due to the side effect of
neuroleptic treatment, the dosage should be reduced, if possible. Anxiety Control.
In controlling anxiety as a comorbid symptom to depression and in anxiety
disorders, antidepressants are the preferred choice for acute and maintenance
treatment. In cases where treatment response is not sufficient, adding short-term
administration of benzodiazepines may be necessary. PSYCHOTHERAPY
Treatment in prevention of suicide requires a complex approach of psychosocial,
psychotherapeutic, and psychopharmacological interventions. Suicide cuts across
the whole spectrum of psychiatric illnesses and therefore therapists should be
familiar with several therapeutic schools and strategies as they give valuable
contributions to the treatment of suicidal persons. The choice of treatment
depends on the condition of the patient. The combination of
psychopharmacological treatment with psychotherapy should always be taken
into consideration as part of a complex treatment strategy. Cry for Help Suicidal
communication both verbal and nonverbal must be taken seriously, independent
of whether the clinician considers that the patient has a genuine wish to kill
him/herself or if the purpose is to get attention. Suicidal communication always
conveys an underlying sense of helplessness and hopelessness and a cry for help.
Risk of Suicide during Treatment Treatment of suicidal patients is challenging, as
the possibility of death by suicide is ever present, independent of whether the
treatment is pharmacological or psychotherapeutic. Establishing an empathetic
relationship with the patient when the threat that the patient might commit
suicide is present, can be difficult. This can be a discouraging condition to work
under. Treatment of a suicidal person requires self-involvement and
confrontation with one’s own attitudes toward life and death. In treating suicidal
patients, one must allow the patient to feel suicidal and not to minimize, reject, or
deny the seriousness of their suicidal intent. Suicidal patients must be allowed to
feel that their pain can be shared with another person. The challenge is to follow
the patient and to understand, as well as to utilize psychotherapeutic methods
without denying suicidality. Transference and Countertransference Suicidal
patients have many different feelings toward their therapists and doctors, which
in the psychotherapeutic literature are called transference. Therapists and
doctors also have feelings toward their patients, which are called
countertransference. Countertransference feelings toward suicidal persons can
be empathetic but ambivalent, aggressive, and even hostile. It implies
understanding of one’s own attitudes and values, as well as origins of suicidal
patient positive and negative feelings toward the clinician. A therapeutic alliance,
which is important to establish, comprises elements of a real relationship
between the therapist/doctor and the patient, as well as aspects derived from
patient’s experiences of earlier relationships, which are transferred to the present
treatment situation. Long-Term Psychological Treatments Two long-term–based
treatments, cognitive behavioral therapy (CBT) and dialectical behavioral therapy
(DBT), show the strongest evidence in preventing suicidal behaviors. There are
also a sufficient number of studies of good quality showing promising results in
the treatment of suicidal patients with family psychotherapy, developmental
group therapy, psychodynamic therapy, and in-home interpersonal
psychotherapy. Interpersonal psychotherapy (IPT) and psychodynamic
approaches like transference-focused psychotherapy, mentalization-based
treatment, and sequential Brief–Adlerian psychodynamic psychotherapy are
supported by randomized controlled trials in which the psychodynamic approach
was found to be effective in reducing suicidal behavior among patients with BPD.
Other therapies like Collaborative Assessment and Management of Suicidality
(CAMS) are using a combination of therapeutic techniques from multiple
previously studied interventions. Brief Psychological Treatments Brief
psychosocial suicide preventive interventions with some empirical support are
CBT-based interventions, contact interventions, combination of those two
approaches, and manual assisted cognitive behavioral therapy (MACT).
Psychosocial support and involvement of family, friends, and significant others
after obtaining consent from the suicidal person is also recommended. Supportive
Telephone Calls and Letters Treatments consisting of supportive telephone calls,
SMS, or written contacts after discharge of the suicidal patient from the
emergency department or hospital showed preventive effects. Involving
community resources with the goal that the social intervention should give
support to the patient in breaking through loneliness and finding social networks,
and in this way, enhancing a sense of meaning in their lives is essential.

SURVIVORS

The term suicide survivors refers to those who have lost a significant other in
suicide. When suicide occurs, the family and the surrounding people experience
severe trauma and a range of reactions from shock, sense of unreality, sadness
and grief reactions, anger, and feelings of abandonment and rejection. Suicide
survivors experience a devastating event and desperately seek an explanation of
what has happened. Not seldom they take contact with the family doctor or
doctor who treated the patient and who also is a survivor of the patient’s suicide.
It can be wise to ask an experienced colleague to help with advice on how to
manage this situation. The doctor needs not only to work with their grief, but also
to assess the potential suicide risk in survivors, who have a high risk for suicide.
The development of support groups can be considered as an important step
forward to work through the aftermath of suicide in a compassionate and
supportive way, educate about grief, demystifying suicide, eliminating excessive
guilt, shame, and blaming. The WHO issued guidelines on how to form support
groups.

PUBLIC HEALTH PERSPECTIVE AND PREVENTION Controlling the Environment The

fatality of suicide methods varies and the rationale behind WHO
recommendations to diminish access to suicide methods is to curb a sudden and
strong impulse to end one’s life. Several studies on the restriction of access to
firearms, pesticides, carbon monoxide and vehicle exhaust, charcoal burning,
placing barriers at hot spots used for jumping, reducing access to medications,
and controlling access to railroads and subways, is an effective approach in
suicide prevention and should be incorporated not only at the public health level
but also at the clinical level. One of history’s most effective suicide prevention
program was observed in the second half of the 1980s in the former USSR during
Gorbachev’s Perestroika (restructuring), characterized not only by openness and
freedom, but also by the strict limitations on the access to alcohol by cuts in the
production and sale, primarily with the aim to improve the health of the
population. Suicide for men decreased by 40 percent in the years 1984 to 1986 in
comparison with 3 percent in 22 European countries during the same period. This
decline occurred in all 15 republics of the former USSR. The sharp decrease in
suicide applied to women as well as men. The largest decreases were observed
among men in the workforce aged 25 to 54 years. No corresponding decline for
this age group was noted in any country during the 20th century. The Role of the
Media in Suicide Prevention Sensational and irresponsible reporting by different
types of media may precipitate or induce suicidal acts through imitation or
identification mechanisms in suicidal persons. The WHO issued guidelines on
media coverage, describing how the press and broadcasting media should report
on suicide in order to avoid copycat effects. It is essential to avoid the description
of suicide as courageous or desirable. School-Based Suicide Prevention Children
and young people spend many hours each day at school and the school is a good
arena for comprehensive suicide preventive work involving a continuum of
activities from mental health promotion, prevention, intervention (treatment),
and postvention when suicide occurs in school. Mental health intervention in
school gives the opportunity to overcome mental health problems and
inequalities while adolescents’ brains are still developing. Results from
randomized controlled trials of classroom-based intervention programs in the
United States, like Signs of Suicide (SOS) and Good Behavior Game (GBG), along
with the SEYLE study show that suicidality can be prevented. The Youth Aware of
Mental Health (YAM) suicide preventive program used in SEYLE aims at changing
adolescents’ negative perceptions and improving coping skills in the management
of negative life events and stressors causing suicidal behaviors. The YAM program
has reduced severe suicidal ideation with suicide plans and suicide attempts by 50
percent. This effect is higher than effects noted in other successful public health
interventions like bullying and bullying victimization (7 to 23 percent), and school-
based interventions addressing smoking cessation (14 percent). The YAM program
is perceived as stimulating by young people and adult instructors. However, in
each classroom, there are a small number of children and adolescents in need of
qualified psychiatric care. To secure both preventive aspects and treatment
aspects for young people in schools, stakeholders must build continuously,
models for collaboration across the education and health care systems interface.

▲ 32.2 Suicide Treatment HOWARD S. SUDAK, M.D.

INTRODUCTION This chapter focuses on ways to identify individuals and groups

at particular risk for suicide and how to prevent them from acting on such
impulses (Table 32.2–1). Although the theoretical goal as clinicians may be to
prevent all suicide attempts and completions, it is clearly not possible— however,
reducing attempts and completions is both possible and feasible. Furthermore,
“suicide treatment” encompasses a broad spectrum of “patients.” Whom are we
treating? The attempter, the individual considering it, the family of the attempter
or completer, or even the public when the victim is prominent or the act so
dramatic? A discussion of working with each of these groups follows. The
Attempter. A patient who indicates that he or she is suicidal or one who has just
attempted suicide represents a psychiatric emergency. And, since patients who
express intent to kill others are extremely rare, attempters and those planning an
attempt comprise the majority of the psychiatric emergencies managed by
clinicians, aside from pharmacological and general medical emergency situations.
Since the condition of having serious thoughts of suicide may be a “symptom” of
a disease, not a disease per se, conventional wisdom has dictated that it is the
disease which needs to be treated, not one of its symptoms. One treats a
depression with antidepressants, a psychosis with antipsychotics, a mania with
mood stabilizers, etc. But this is not universally true. Clinicians treat other
symptoms (e.g., fever, headaches, and most viral infections symptomatically with
aspirin); insomnia with hypnotics; constipation with laxatives, etc. and, to some
degree, this holds true for suicide as well. Dialectical behavior therapy (DBT), a
treatment specifically designed for patients with BPD also appears useful in some
other impulsive psychiatric conditions such as nonsuicidal self-cutting, as well.
Similarly, lithium, a treatment for stabilizing bipolar patients, appears to be useful
in other conditions. Antipsychotics are not uncommonly used for nonpsychotic
agitation, and so forth. The most common condition associated with suicide is
depression, and the psychotherapies and pharmacotherapies which address this
are all part of the arsenal employed to decrease the risk of a suicide “attempt” or
“completion.” (Note that the term “completion” is preferable to “successful”
suicide with regard to treatment, since an attempt or completion is hardly a
success.) Unfortunately, “suicide attempter” has become almost a pejorative
label, and such individuals too often are treated dismissively and peremptorily by
emergency personnel, as though the attempt is merely a way to control or
manipulate others. Certainly, most emergency rooms (ERs) are understaffed with
stressed-out personnel who too often view attempters as unnecessary burdens
which may stem from staff’s own discomfort, anxiety, and lack of knowledge. A
recent follow-up study revealed that from a total of 65,784 patients seen in
emergency rooms in Canada, during a median follow-up period of 5.3 years, 4,176
had died, including 976 (23.4 percent) by suicide. This is hardly a low-risk
subpopulation. Table 32.2–1. Risk Factors for Suicide Primary Diagnosis
Demographic and Miscellaneous Factors Personality Factors Comorbidities Social
Factors Other Factors Bipolar Male Borderline Substance abuse Divorced Means
available Schizophrenia Older age Narcissistic Panic disorder Widower History of
child abuse Major depressive episode White race Antisocial Anxiety Lives alone
Few reasons to live Dysthymia Homosexuality Conduct disorder Axis III diagnoses
Isolated Lots of adverse events Adjustment disorder with depression History of
attempt Impulsive Money worries Change grades Conduct disorder Family history
Other losses Change friends Psychosis Suicidal ideas No religion Giving things
away Hopeless Helpless Guns in the home Helping Significant Others When a
Suicide Occurs. Foremost among “others” is the decedent’s family. Assuming that
they desire help, they may be referred to a local “SOS” (Survivors of Suicide)
group near them. Both the American Foundation for Suicide Prevention (AFSP—
headquartered in New York) and the American Psychological Foundation can
provide a geographic directory for such groups. SOS groups are not designed for
those who have attempted suicide but failed to die (although such persons are
clearly in need of help, since SOS groups exist to support individuals bereaved by
suicide). Some SOS groups are reluctant to have family members attend meetings
immediately after their loved one’s death because they have a difficult time
managing in groups, not letting others speak, since they are too aggrieved to
contain themselves. Meetings are generally conducted by other survivors, rather
than mental health professionals, on the principle that they “know” and
empathize with what the families are suffering better than do the professionals.
This certainly does not mean that the treating professional’s role ceases following
a patient death. Attending the funeral, meeting with the family to offer
condolences and to discuss with them whatever is possible within the bounds of
confidentiality is generally perceived by grieving families as helpful. Following a
patient’s suicide, many mental health professionals are reluctant to have any
contact with the decedent’s family—often because they feel so guilty or are so
frightened of litigation that they wish to terminate all contact. However, such
contact may actually diminish such an outcome and be comforting to the family.
The mental health provider is a survivor, as well. In the article, “Client Suicide—
What now” the authors note that of 30,000 suicides per year, 10,000 were in
treatment during the preceding year and 6,000 were in treatment in the
preceding month. Because having one’s patient suicide is so traumatic for
therapists, they often seek help for themselves. Institutional review boards which
routinely conduct suicide reviews, postmortems, or “root-cause” reviews are
generally designed with the institution’s needs in mind, not necessarily the
therapist’s, so that therapy and support for the involved provider can be
extremely helpful. “Significant others” also include classmates, coworkers, and
friends of the victim and mental health professionals may become involved in
assisting and supporting them, as well. There are a number of programs to assist
schools in handling some of the emotional distress produced by a schoolmate’s
suicide. The AFSP has printed guidelines available to schools at no cost, as have
many other organizations. These suggestions include the recommendation that
schools should avoid permanent memorials to decedents, for instance, and other
similar steps to avoid “contagion effects” resulting in additional suicides. Similarly,
other organizations, including the University of Pennsylvania’s School of
Journalism, and others have published guidelines for the media to help them
present suicide information in ways which do not engender “copycat” suicides.
The Neurobiology of Suicide There is a large and exciting literature on underlying
neurobiological aspects of suicide. For instance, Oquendo et al.’s 2014 article
“Toward a Biosignature for Suicide,” includes a review and synthesis of the
research literature of the biomarkers of suicide in order to develop a coherent
model for the biological underpinnings for suicidal behavior. The authors note
that several lines of evidence indicate that stress response systems in suicidal
individuals become dysregulated, especially the HPA (cortical– hypothalamic–
pituitary axis), constituting a diathesis for suicide. Additional findings, such as
neuroinflammatory indices, glutamatergic function, and neuronal plasticity may
be a reflection of the downstream markers of such dysregulation. They suggest
that studying these systems in the same populations may reveal the role and
interplay of each. This could lead to new treatment targets and biological
predictors. Guintivano’s group has identified a combined genetic and epigenetic
biomarker, SKA2, in the prefrontal cortical tissue obtained from the Stanley
Medical Research Institute and the Harvard Brain Bank at McLean Hospital. This
group subsequently replicated their results with peripheral blood from three
living groups. They found that SKA2 gene expression was significantly lower in
suicide decedents and was significantly associated with genetic and epigenetic
variation in the rs7208505 region of the SKA2 gene. They suggest that the SKA2
genetic and epigenetic variation represents an underlying state which increases
suicide risk in the presence of a stressor. Although these preliminary findings
need to be replicated by others, they represent at least one aspect of the promise
of neuroscientific inquiry. The Suicide Inquiry It cannot be stressed enough that
every psychiatric evaluation must include a documented suicide inquiry. If there is
no indication of a prior suicide ideation or attempt or depression this may be
brief. Be certain you are not inadvertently signaling that you’re looking for a
negative answer, as in “you’re not suicidal, are you?” Better to start with “have
you ever wished you were dead?” or “ever thought seriously about suicide?” The
inquiry proceeds stepwise until the physician feels reassured that the patient is in
no need for more restrictive treatment. If the patient is psychotic and/or
depressed, one needs to expand the inquiry. “How depressed are you” or “does it
ever get so bad that you wished you were dead?” or “that you ever thought about
suicide?” “Have you ever felt suicidal at another time in your life?” “Have you
ever attempted it?” Any complete assessment must include “any family history of
attempts or completions?” If a patient responds affirmatively to “have you now or
ever felt you wished you were dead” it is often helpful to ask “are you concerned
that you might harm yourself?” If the patient says “no” you then need to wonder
if he or she is only saying “no,” because he thinks that’s what you want to hear. If
he says “yes, I am worried,” you should be quite concerned. Asking other
informants, such as the patient’s spouse or other family members accompanying
the patient to your office or telephoning the patient’s spouse should you be
suspicious that the patient may not have been forthcoming with you, is also
helpful (assuming that the patient agrees). Note that if you are very concerned
that the patient is minimizing his suicidality, you may tell the patient that you
need to speak with his or her spouse even without consent because you are so
concerned. Your assessment about the acuity of the situation determines what
you do next. If you feel that the patient needs to be admitted directly from your
office, you or a responsible adult (e.g., the patient’s spouse, a nurse or aid, a
parent, or other responsible adult) needs to be constantly with the patient until
he or she is transported (and presumably admitted) to a psychiatric facility which
is capable of caring for such patients. “Constantly” includes use of the bathroom,
a common site for attempting or completing suicide. The most privacy one should
allow is that the bathroom door be left ajar. Now, in an era of hospitalists
generally being the ones to care for your private patients, your decision to seek
hospitalization may not necessarily suffice. What if the hospital staff feels that
admission isn’t required and that the least-restrictive environment rule applies
and says your patient may leave? If you agree, fine. If you remain convinced that
this is too unsafe, you can try to convince the staff of the need. If that fails, you
may try to arrange admission elsewhere, or seek a commitment, assuming the
family agrees with you. These may be painful decisions which complicate your
busy schedule but life, injury, or death may hang in the balance and “you’re it”
and have to do what the prudent physician would do—meaning, doing your best
to insure the patient’s safety. For those physicians who believe that such efforts
on behalf of their patients is infantilizing and paternalistic and, therefore, prefer
to be laissez-faire in such matters, if the patient goes on to harm or kill himself,
you may be held responsible, nonetheless, should litigation arise (see section on
Suicide and Malpractice). There are numerous “suicide risk scales” in use. One of
the best of these is the Columbia Suicide Severity Risk Scale (C-SSRS), which was
determined to be reliable and valid in three multisite studies. An excellent recent
review article is “Training for Suicide Risk Assessment and Suicide Risk
Formulation” in which the authors describe two components of the evaluation:
assessing the risk factors and then formulating the level of risk. Despite the
general belief that active suicide ideation is more predictive of an event occurring
than passive, they do not believe that this is so, nor do they see that “active” is
more predictive of death by suicide than “passive” ideation. They agree with A.T.
Beck’s contention that learning about suicide ideation at its worst point is a better
predictor of death by suicide than current suicide ideation or hopelessness. They
feel that “warning signs” primarily relate to suicide over the next 12 months, not
necessarily “near” events, and cite other work showing that, in their last contact
with suicidal patients, therapists estimated “no risk” in 30 percent and “low risk”
in 54 percent of patients who killed themselves before their next visit. Further,
they cite Spangler’s study of 4,600+ clinicians and conclude that education and
clinical experience results in only 13 percent accuracy of their clinical judgments!
“Competence can only develop with extensive deliberate practice and corrective
feedback.” They (wryly) note that all clinicians feel they are competent judges,
nonetheless. Suicide and Malpractice What standard of care applies to patient
suicide? The usual cliché is that “the psychiatrist isn’t expected to predict all
suicides,” only to properly appraise the “risk” of it and to determine how
“foreseeable” the risk is. Although correct in theory, it is more accurate to
conclude, “it all depends on the judge and the jury.” Most psychiatrists will have
at least one suicide in their careers. The great majority of these do not proceed to
litigation. Psychiatry residents, unfortunately, not uncommonly have patients who
suicide. Then, if litigation ensues, it is generally against the institution and the
attending physician as well as the resident. The resident is often called as a
witness but not held financially accountable. This is of small comfort to the
resident because he has less capacity for perspective to fall back on and less
confidence—hence, the critical need for support programs for such residents,
lawsuit or not. How does the prudent psychiatrist keep his risk at a minimum? The
medical record will generally be decisive in court proceedings so it behooves
clinicians to absolutely ensure that the record accurately reflects the evaluation,
diagnosis, the suicide inquiry, estimation of risk, treatment plan, course, results,
etc. Any contact with the patients’ family to corroborate the diagnosis and explain
the treatment should be documented. The inquiry about available means for
suicide, for example, guns in the home, potentially lethal medications, etc., should
be detailed. If there is reason to believe that the patient might be suicidal, was he
asked about it at every visit and was this documented in the chart? Did the
therapist ask about past history and family history of suicide? Did he ensure that
the doses and types of medicine prescribed were reasonably safe, effective, etc.?
Were the number of pills prescribed and their doses excessive or insufficient for
the situation? A good relationship between the provider and the patient’s family
may be the most critical factor in terms of avoiding lawsuits after a suicidal death.
Importantly, even the best care may not protect against litigation ensuing and
then it will all be up to the defense attorney, the plaintiff’s attorney, credibility of
the plaintiff’s and defendant’s “expert witnesses,” and, ultimately, the judge and
jury. Note, too, that merely because a judgment for malpractice has been
obtained does not mean one is an inadequate psychiatrist! Therapy Introduction.
The most effective treatment for preventing suicide is undoubtedly combined
treatment—that is, both psychotherapy and pharmacotherapy targeting the
underlying psychiatric disorder while working specifically on the suicidal behavior.
As stated in the Introduction section, however, there are some approaches, both
psychological and pharmacological, which may transcend the “underlying disorder
concept,” for example, CBT for a wide array of apparently discrete mental
disorders; major and minor tranquilizers for anxiety and agitation across diverse
disorders, etc. Nonetheless, for clarity and simplification, medications and
psychotherapy are discussed separately here. A major, critical, problem is to find
effective treatments for suicide outcome studies is that “suicidal” patients are
generally avoided as research subjects because of ethical and medicolegal
concerns re litigation should they die or seriously injure themselves while so
enrolled. Role of the Hospital. When the patient appears to be so suicidal, so
unreliable about his intent or untrustworthy regarding his intent, or so out of
control that the therapist feels hospitalization is necessary to protect him, then
hospitalization is required. Although this sounds simple and straightforward, as
discussed earlier, this is a complex situation, even when the patient and his
significant other agree. Since the therapist generally is not the decider of who
gets admitted, the therapist will need to provide a convincing reason for “why
now in?” Assuming that hospital staff agree to keep the patient, they may or may
not want your input in helping decide what level of care is required: closed or
open unit, single or double room, frequency of observation, etc.? Presumably,
you (the therapist) and the hospitalist will work together on this. Before your
patient can be safely discharged, however, virtually the same question must be
asked by the attending, namely “why now out?” What has changed to indicate
that he is now safe? The mere fact that he has been in the hospital for a few days,
in itself, is insufficient evidence. How has his improved outlook been
documented? Just because he’s taking his medicines and attending groups is not
sufficient evidence by itself. What do staff and his family report? Such evidence
must inform the discharge plan. Somatic Treatment. Obviously, somatic
treatment has to be tailored to the underlying condition, for example, depression,
bipolar disorder (both manic and depressed phases), schizophrenia, substance
abuse, etc. However, when selecting an agent for a patient deemed “suicidal,” it is
preferable to select one with known antisuicide effects such as lithium for bipolar
patients or clozapine for psychotic or bipolar patients, assuming that there are no
contraindications for such choices. In BPD, the best approach is psychological
(e.g., transference-focused therapy, “mentalization-based” behavior therapy, or
DBT) rather than pharmacological (unless the BPD is accompanied by a comorbid
disorder which responds to medication), since no medications have yet been
proven effective for this disorder. Psychotherapy. There is recent evidence that
psychotherapies may specifically target suicide. The best example of this may be
DBT for BPD. Although DBT has come to be regarded as the gold standard for
treating BPD, there are a few studies showing that other therapies may be equally
valuable in reducing suicidal behaviors. An interesting comparison study was
carried out by Clarkin et al., comparing 90 BPD patients treated by experienced
clinicians using three modalities: transference-focused psychotherapy, DBT, or
supportive treatment (along with medication, as indicated) for 1 year. Patients in
all three groups showed a significant positive change in depression, anxiety,
global functioning, and social adjustment. Both DBT and transference-focused
therapies were significantly associated with improvement in suicidality. Only
transferencefocused and supportive therapies were associated with improvement
in anger and impulsivity. Only transference-focused was significantly predictive of
change in irritability, and verbal and direct assault. CBT is another highly valued
treatment for suicidal behaviors. A 2012 article in The Behavior Therapist,
indicates that suicidal behavior should be viewed as the primary problem rather
than merely viewing this behavior as a symptom of a psychiatric disorder. The
authors target specific cognitions and behaviors which fuel suicidal behavior. They
detail an approximately 10-session program and note that, in an 18-month follow-
up, 24 percent of the CBT-treated patients versus 42 percent of the treatment as
usual (TAU) ones made at least one additional attempt. Daniel and Goldston,
guest editors for a special series, “Working with a Suicidal Client—Not Business as
Usual,” noted that “until recently, suicide literature focused on risk factors and
assessment, and treatment focused on the ‘underlying DSM-5 disease’ in which
suicide is seen as a symptom of another disease such as depression, psychosis,
etc., and on prevention.” In this same “special series,” Linehan, Comtois, and
Ward-Cieleski note that the paucity of random controlled trials is a major reason
that suicide rates have barely budged in the past 100 years. In addition to DBT
and CBT, there are other therapeutic approaches which appear to be helpful for
suicidal patients. One of them is mindfulness. As Luoma points out, experiential
avoidance, the tendency to avoid or escape from unwanted psychological
experiences, may produce harmful consequences like suicidal behaviors.
Mindfulness and psychological acceptance may serve as a means to target
experiential avoidance, thereby decreasing the risk of suicide. This approach
directs treatment of suicide not solely as a symptom of disease but as the primary
target of therapeutic efforts. Mindfulness is a key feature which overlaps the four
psychological processes in acceptance and commitment therapy (ACT).

SPECIAL POPULATIONS Military. For both active duty and, to a lesser extent
retired, military personnel have increased rates of attempts and completions. A
recent study by Rudd et al., found that eight participants in a brief CBT treatment
(13.8 percent) versus 18 subjects (40.2 percent) treated with TAU made at least
one suicide attempt. Thus, CBT subjects were 60 percent less likely to attempt
than TAU ones. Subjects were drawn from 76 subjects who had either attempted
suicide or had suicide ideation with intent to act and were treated with TAU
versus 76 attempters or serious ideators treated with CBT + TAU. Adolescents.
Depression in adolescents is less likely to manifest the same symptoms as in
adults. Verbal or even physical aggression is just as apt to be seen as sadness,
tearfulness, etc. Giving prized possessions away (books, clothes, CDs, etc.) or
changes in behavior (becoming unruly, uncooperative, abruptly starting to use
drugs or alcohol) may be all that the parents note as changed. Similarly, a drop in
grades in a student who has always done well may be all that is observed by the
parents. More “moodiness” or more sleep irregularity are common symptoms but
not as common in adolescence as to be poor markers for depression. School-wide
suicide screening examinations, such as the Columbia Teen Screen are now widely
used in junior and senior high schools in this country to help identify those
students at increased risk for depression and suicide. The Elderly. The geriatric
population has the highest ratio of completion to attempts. That is, when they
attempt suicide, it is more frequently a lethal attempt than the methods seen in
younger populations. They are also harder to predict, partly because their
depressions are more likely to be misperceived as “normal” (“of course he’s
depressed, he’s old, feeling useless and tired, so it’s just natural”). The suicide
rates for the elderly have been the highest of any age group for approximately the
past 250 years but, beginning around the year 2000, rates in 40 to 65 year olds
rose enough to surpass the 65+ year olds. The Publicly Shamed. Defrocked clergy,
disbarred attorneys, de-licensed physicians, and other “prominent and respected”
individuals, who have became publicly shamed due to one scandal or another
(e.g., undue familiarity; child molestation; financial “mischief,” etc.) are
anecdotally reported to have suicide rates within the year following their “outing”
higher than any other subgroup. Victim-Precipitated Suicide. Also known as
suicide-by-cop, is a particularly cruel method of killing oneself since the pain it
engenders is not only to the decedent’s friends and family but also to a totally
innocent person. The unfortunate policeman who is confronted by a stranger who
appears to be homicidal and who shoots and kills that stranger thinking his own
life or some third party is in danger, ends up becoming a victim himself. The
legacy of suicide is terrible enough without making someone else responsible.
Jumping to one’s death in front of a passing train or car leaves a similar painful
legacy for innocent second parties. Physician-Assisted Suicide. Already first legal
in Oregon and now a few other states, the right for physicians to prescribe (and
administer) lethal doses of medications to terminally ill and suffering patients, will
undoubtedly expand. Although this appears humane, the potential for harm is
real and needs to be guarded against, such as families pressuring infirm and older
relatives to request an end-of-life to serve their own purposes rather than the
patient’s, as Hendin warned against in Seduced by Death. An additional related
concern is that depression is common in chronically medically ill patients and may
result in their pressing of their families to help them die, despite the fact that
most such depressions are treatable. Future Directions. What can one hope for
over the next 25 to 50 years? This writer’s wish list vis-à-vis suicide follows.
Suicide attempt and completion rates will decrease in concert with diminished
gun ownership. The likelihood of that happening is none to minimal, however.
What is more probable is a vastly improved array of medications to rapidly,
effectively, and safely treat (a) depressive and bipolar disorders, (b) substance
abuse, (c) schizophrenia, and (d) personality disorders, especially BPDs. An
apparent taste of this was provided when nearimmediate lifting of depression
appeared to arise when Ketamine was administered and was reported to be a
wonder drug. It wasn’t but that hardly rules out another drug with super-rapid
action coming along. Better pharmacological therapies would result in basic
science discoveries re depression, mania, and psychoses. Also, improved
diagnostic tools will help ensure optimal and prompt diagnoses. In addition to a
vastly improved pharmacology, would go a comparably improved psychotherapy.
CBT, DBT, and psychoanalytically oriented psychotherapy, as well as other
psychotherapies, need to be mastered by all therapists and shortened by
discerning what parts of these are most relevant to suicidal individuals.
Acknowledgment The author wishes to express his appreciation to Dr. Donna
Sudak for her invaluable bibliographic and editorial assistance with this chapter.