Suicide is a complex act that represents the end result of a combination of factors in any individual. These factors include biological vulnerabilities, life history, occupation, present social circumstances, and the availability of means for committing suicide. While these factors do not "cause" suicide in the strict sense, some people are at greater risk of self-harm than others. Risk factors for suicide include:
- Male sex.
- Age over 75.
- A family history of suicide.
- A history of previous suicide attempts.
- A history of abuse in childhood.
- A local cluster of recent suicides or a local landmark associated with suicides. Examples of the latter include the Golden Gate Bridge in San Francisco; Sydney Harbor Bridge in Australia; St. Peter's Basilica in Rome; the Eiffel Tower in Paris; Prince Edward Viaduct in Toronto; and Mount Mihara, a volcano in Japan.
- Recent stressful events: separation or divorce, job loss, bankruptcy, upsetting medical diagnosis, death of spouse.
- Medical illness. Persons in treatment for such serious or incurable diseases as AIDS, Parkinson's disease, and certain types of cancer are at increased risk of suicide.
- Employment as a police officer, firefighter, physician, dentist, or member of another high-stress occupation.
- Presence of firearms in the house. Death by firearms is the most common method for women as well as men as of the early 2000s. In 2001, 55% of reported suicides in the United States were committed with guns.
- Alcohol or substance abuse. Mood-altering substances are a factor in suicide because they weaken a person's impulse control.
- Presence of a psychiatric illness. Over 90% of Americans who commit suicide have a significant mental illness. Major depression accounts for 60% (especially in the elderly), followed by schizophrenia, alcoholism, substance abuse, borderline personality disorder, Huntington's disease, and epilepsy. The lifetime mortality due to suicide in psychiatric patients is 15% for major depression; 20% for bipolar disorder; 18% for alcoholism; 10% for schizophrenia; and 5-10% for borderline and certain other personality disorders.
When a person consults a doctor because they are thinking of committing suicide, or they are taken to a doctor's office or emergency room after a suicide attempt, the doctor will evaluate the patient's potential for acting on their thoughts or making another attempt. The physician's assessment will be based on several different sources of information:
- The patient's history, including a history of previous attempts or a family history of suicide.
- A clinical interview in which the physician will ask whether the patient is presently thinking of suicide; whether they have made actual plans to do so; whether they have thought about the means; and what they think their suicide will accomplish. These questions help in evaluating the seriousness of the patient's intentions.
- A suicide note, if any.
- Information from friends, relatives, or first responders who may have accompanied the patient.
- Short self-administered psychiatric tests that screen people for depression and suicidal ideation. The most commonly used screeners are the Beck Depression Inventory (BDI), the Depression Screening Questionnaire, and the Hamilton Depression Rating Scale.
- The doctor's own instinctive reaction to the patient's mood, appearance, vocal tone, and similar factors.
Specific Steps to Take (From http://www.psychpage.com/learning/library/counseling/suicide.html)
First, remember to do three things:
- consult - this allows for another opinion, better care, and protects you
- document, document, document! Everything you do, everyone you talk to, every question you ask the client should be documented
- evaluate the client's risk
Questions to Ask
- Do you have thoughts of suicide?
- Are they related to current stressors going on in your life, or have you had such thoughts before?
- Do you have a plan? Tell me.
- Ask if they have access to the components of their plan, like a gun, pills, etc…
Signs of depression
- sleep, energy, weight, or appetite changes
- decreased interest in sex and other pleasurable activities
- feelings of helplessness and hopelessness
- social isolation and withdrawal from others
Level of Risk
- none - no suicidal ideation
- mild - some ideation, no plan
- mod - ideation, vague plan, low on lethality, wouldn't do it
- severe - ideation, plan specific and lethal, wouldn't do it
- extreme - ideation, plan specific and lethal, will do it
Highest risk group has suicidal ideation (thoughts of killing self), a plan (any plan so long as it is definite and detailed is high risk), high lethality (guns and walking in front of busses are more serious than overdosing on Tylenol and slashing wrists), few inhibitors (few reasons not to kill self), low self-control (especially drinking or using drugs - can decide not to kill self but fail to act to reverse events and accidentally kill themselves)
Possible Next Steps
- They are experiencing crises and stress, hopelessness, and helplessness. Offer that there is a part of them that wants to live, since they were cooperative with you. Offer too that services and referrals, as well as social support could be helpful to use now too.
- Make a No-Suicide Contract
- This is best when the client has support, is low risk, and can give clear reasons why they would not kill themselves; the client agrees they won't hurt themselves, and if they feel they can't stop themselves, they will call 911, an ER, a crises line, a therapist, or another designated special person, and will return for help on next appointment. Make the patient sign it and get a witness.
- Family Intervention
- This is best is there is high support and low impulsiveness in the client. The clients agree with you to contact their family. They stay with the family member until the suicidal thoughts have been addressed in treatment, and the family is briefed on who to contact for help in an emergency. The family also takes an active role to remove drugs, guns, or other means of suicide from the home, and promises 24 hour supervision.
- This is best if there is little family support, or mental illness, substance use or impulsiveness. Try voluntary admission, but use involuntary if needed.