This article addresses both the epidemiology of suicide and assessment of suicidal thoughts and behaviors. The use of term suicidality is strongly discouraged, as it is confusing and non-specific (see below).
Among the general US population, yearly suicide rate is 10-13 per 100,000 depending on the year, or ~1.3% of all deaths. It's 10th leading cause of death, with 35,000+ deaths/year.
- In 2013, 41,149 suicides were reported: 13.0 per 100K, with firearms (6.7 per 100K) and suffocation (3.2 per 100K) as most common methods. CDC
Understanding the Statistics
The ranking as "Xth leading cause of death" is informative in some respects, but misleading in others: for example, suicide rates are higher in patients 65 and older than in the general population, with rates of 14.3 per 100,000 (NIMH). However suicide is not on the top 10 leading causes of death in the elderly, because CVD, cancer, diabetes, dementia, etc. claim so many more lives with much higher rates. In youth 10-14 yo, suicide is relatively rare (low rate), but still ranks as the 3rd leading cause of death (after unintentional injury and neoplasms)()
- Suicide is the 3rd leading cause of death in adolescents and young adults;
- Suicide rate among 10-19 year olds is 4.9 in 100,000.
- Older male teenagers are at higher risk for suicide, with rates approaching 20 per 100,000 for 19 year olds.
- By race, Native American youth have the highest suicide rates, 14.3 per 100,000, closely followed by non-Hispanic whites (13.4 per 100,000).
- In 2006, 6.95% of youth made at least one suicide attempt.
- M:F teen suicide completers is at least 3:1. More females attempt suicide than males, but more males complete suicide.
- About two-thirds of individuals who commit suicide are depressed.
- Sexual abuse is a major risk factor for adolescent suicide attempts and reattempt. Up to 20% of adolescent suicide attempts are attributed to sexual abuse-related PTSD; these adolescents are also eight times more likely to reattempt suicide as compared to their suicidal peers who were not sexually abused. (JACAAP PTSD parameter p.416)
- Family history of suicide increase the risk of suicidal behavior 4-10x, independently of other psychopathology.
A Consensus panel (Meyer 2010) recommended that the term suicidality be abondoned in favor of terms used by the Columbia Classification Algorithm of Suicide Assessment (C-CASA):
The umbrella term Suicide Event includes:
- Completed Suicide - deadly self-injurious behavior associated with some intent to die.
- Suicide Attempt - self-injurious behavior with some intent to die.
- intent may be stated/explicit or clinically inferred from seriousness of the event.
- a self-injury that did not result in any harm is still a suicide attempt if intent to die as a result was present.
- Preparatory acts toward imminent suicidal behavior - this includes patients who prepared for or began a behavior leading to self-injury with intent to die only to be discovered and interrupted.
- Suicidal Ideation - Thoughts about dying (passive SI) or killing self (active SI) without preparation
Many incidents will be outside the above definitions of suicide event, e.g.
- purposeful self-injurious behavior without suicide intent
- non-deliberate self-injury
- self-injury where intent is unknown and can not be inferred from the details of the incident (e.g. a child who learns that his favorite teacher is leaving and starts scratching his wrist with a pencil)
- other incidents lacking information (e.g. school note: "child stabbed himself in the neck with a pencil" does not mention if the self-injury was deliberate or if suicidal intent was present)
Assessment and Screening
The Modified Scale for Suicide Ideation is available online. It's an 18-question clinican-administered scale of acute (past 48 hours) suicidality; it allows a score of 0-3 for most of the questions. Serious Suicidal Ideation is defined as presence of the following 4 factors: total score >20, Intensity score >1 (Range 0-3), active suicidality >1, and plan/method specificity >1. Total score of 9-20 signifies Mild to Moderate Suicidal Ideation.
Risk Factors for completed suicide can be classified as acute and chronic (Freeman S):
Acute Risk Factors (within 1 year of initial assessment) include psychotic anxiety, global insomnia, diminished concentration, panic attacks, alcohol abuse, and anhedonia. Benzodiazapines may be effective in reducing some of these risk factors (not necessarily preventing suicide). Antipsychotics can reduce psychotic elements contributing to suicidality risk. Anti-depressants may have a role in decreasing acute suicide by treating depression despite the black-box warning of increased suicidal ideations in some young people. ECT may be indicatied for "acute suicidality."
Chronic Risk Factors include a number of diagnoses, including mood disorders, schizophrenia, anorexia nervosa, substance use, Cluster B PD, chronic pain, and other medical comorbidities. Other red flags include hopelessness and h/o suicidality. Treatment of specific illnesses can decrease overall risk of suicide. Lithium, Clozapine and ECT had been associated with reduction in overall suicide risk.
- Prevention by targeting high-risk groups in schools and general population is generally believed to be effective.
- Lithium is colloquially believed to have "anti-suicide" properties, but there is no conclusive evidence that the effect is greater than what would be expected from a medication that treats a chronic mood disorder.
- according to a meta-analysis (Cipriani, BMJ 2013), lithium was associated with a 60% reduction in risk of suicide when compared with placebo, and also a reduced risk of deliberate self harm compared with carbamazepine.
- it concluded that "lithium is an effective treatment for reducing the risk of suicide in people with mood disorders. Lithium may exert its antisuicidal effects by reducing relapse of mood disorder, but additional mechanisms should also be considered because there is some evidence that lithium decreases aggression and possibly impulsivity, which might be another mechanism mediating the antisuicidal effect."
- Suicidality in bipolar depression is notoriously hard to treat ,with 20% of patients eventually taking their own lives.
- combination of sleep deprivation therapy, lithium, and light therapy was shown to rapidly decrease depressive suicidality in a cohort trial in treatment-resistant bipolar inpatients .
Meyer RE et.al. Suicidality and Risk of Suicide—Definition, Drug Safety Concerns, and a Necessary Target for Drug Development: A Consensus Statement. J Clin Psych 2010 71(8):e1-e21.
Posner K, Columbia Classificaiton Algorithn of Suicide Assessment (C-CASA), Am J Psych 164:7 1035-43.
Freeman SA, Suicide Risk and Psychopharmocology: Assessment and Management of Acute and Chronic Risk Factors. J Clin Psych 70:7 1052-53.
Cipriani, A., et.al. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ. 2013;346:f3646