Mortality Rates - Suicide
- 300,000 people die from AIDS
- 850,000 people die from car accidents
- 920,000 people die from malaria
- 970,000 people die from lung cancer
- 820,000 people die from suicide
World Health Organisation (1997)
Psychiatric Diagnosis
- Of 6,003 cases of suicide, the cause was:
- Organic brain syndrome - 5%
- Substance abuse - 16%
- Schizophrenia - 10%
- Affective disorders - 24%
- Neurotic and personality disorders - 22%
- Other mental disorders - 21%
- No diagnosis - 2%
World Health Organisation (1997)
The presence of a psychiatric disorder (including alcohol and drug abuse) is the strongest risk factor for suicide, so that the prevention and treatment of psychiatric disorders would undoubtedly have a significant effect on the number of suicides. It is widely accepted that over 90% of those in the USA and Europe who succeed in committing suicide have a psychiatric illness at the time of death.
Assessing Suicide Risk
Factors to Consider in Evaluating Suicide Risk
- Lifetime history of attempts
- Suicidal ideation
- Access to means for suicide
- Hopelessness/self-esteem
- Anxiety
- Impulsivity
- Aggression and violence
- Cognition
- Psychotic symptoms
- Comorbid psychiatric disorders
- Psychiatric hospitalization
- Disabling medical illness
- Demographic features
- Psychosocial stressors
- Absence of psychosocial support
- History of childhood traumas
- Family history of or recent exposure to suicide
- Absence of protective factors
- Alcohol or other substance abuse
Re-evaluate risk periodically as treatment proceeds
Numerous false negatives and false positives complicate risk assessment
Suicide: A Multi-Factorial Event
- Psychiatric Illness Co-morbidity
- Neurobiology
- Impulsiveness
- Hopelessness
- Family History
- Psychodynamics/Psychological Vulnerability
- Suicidal Behavior
- Access To Weapons
- Life Stressors
- Substance Use/Abuse
- Severe Medical Illness
- Personality Disorder/Traits
Suicide (Risk) Assessment
Suicide (risk) Assessment refers to the establishment of a clinical judgment of risk in the very near future, based on the weighing of a very large mass of available clinical detail. Risk assessment carried out in a systematic, disciplined way is more than a guess or intuition – it is a reasoned, inductive process, and a necessary exercise in estimating probability over short periods.
Components of Suicide Assessment
- Appreciate the complexity of suicide / multiple contributing factors
- Conduct a thorough psychiatric examination, identifying risk factors and protective factors and distinguishing risk factors which can be modified from those which cannot
Suicide Assessment Guidelines
- Ask directly about suicide; The Specific Suicide Inquiry
- Determine level of suicide risk:
- Low, moderate, high
- Determine treatment setting and plan
- Document assessments
Characteristics of a Suicide Plan
Risk / Rescue Issues:
- Method
- Time
- Place
- Available means
- Arranging sequence of events
Jacobs (1998)
Suicide Risks in Specific Disorders
| Condition | RR | %/y | %-Lifetime |
|---|---|---|---|
| Prior suicide attempt | 38.4 | 0.549 | 27.5 |
| Eating disorders | 23.1 | 0.310 | 15.5 |
| Bipolar disorder | 21.7 | 0.292 | 14.6 |
| Major depression | 20.4 | 0.275 | 14.7 |
| Mixed drug abuse | 19.2 | 0.173 | 8.6 |
| Dysthymia | 12.1 | 0.143 | 8.2 |
| Obsessive-compulsive | 11.5 | 0.160 | 7.2 |
| Panic disorder | 10.0 | 0.121 | 6.0 |
| Schizophrenia | 8.45 | 0.101 | 5.1 |
| Personality disorders | 7.08 | 0.084 | 4.2 |
| Alcohol abuse | 5.86 | 0.026 | 1.3 |
| Cancer | 1.80 | 0.014 | 0.72 |
Adapted from A.P.A. Guidelines, part A, p. 16
The Tool for Assessment of Suicide Risk: TASR
NAME: ___________________________________________ Chart #: ________________
INDIVIDUAL RISK PROFILE:
- Male
- Ages 15-35
- Age over 65
- Family history of suicide
- Chronic medical illness
- Psychiatric illness
- Poor social supports/social isolation
- Substance abuse
- Sexual/physical abuse
SYMPTOM RISK PROFILE:
- Depressive symptoms
- Positive psychotic symptoms
- Hopelessness
- Worthlessness
- Anhedonia
- Anxiety/agitation
- Panic attacks
- Anger
- Impulsivity
INTERVIEW RISK PROFILE:
- Recent substance use
- Suicidal ideation
- Suicidal intent
- Suicidal plan
- Access to lethal means
- Past suicide behaviour
- Current problems seem unsolvable to patient
- Suicidal/violent command hallucinations
LEVEL OF SUICIDE RISK:
- High [ ]
- Moderate [ ]
- Low [ ]
Assessment completed by: ___________________________
(Name & position)
© Dr. Stan Kutcher & Dr. Sonia Chehil, 2005
DATE: ___________________________
When to Document Suicide Risk Assessments
-
At first psychiatric assessment or admission.
-
With occurrence of any suicidal behavior or ideation.
-
Whenever there is any noteworthy clinical change.
-
For inpatients:
- Before increasing privileges/giving passes
- Before discharge
-
The issue of firearms:
- If present - document instructions
- If absent - document as pertinent negative
Suicide Assessment
Competency
-
Document:
- The risk level
- The basis for the risk level
- The treatment plan for reducing the risk
-
Example: This 62 y.o., recently separated man with recent stroke is experiencing his first episode of major depressive disorder. He is denying having death wishes or current suicidal ideation. He had a serious suicide attempt 5 years ago and he has continued anxiety and hopelessness.
