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Introduction

This article addresses both the epidemiology of suicide and assessment of suicidality.

Epidemiology

Suicide is the 3rd leading cause of death in 15-24yo age group; suicide rates are highest in patients 65 and older. (Meyer, 2010)

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.

Definitions

Suicidal Events from the Columbia Classification Algorithm of Suicide Assessment (C-CASA)

  • 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, 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)

Screening

Assessment

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.

Prognosis and Management of Risk

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.

References

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.