History and exam
Key diagnostic factors
common
previous suicide attempt or self-harm episodes
Frequency, context (e.g., time, setting, planning, substance use, impulsivity, witnesses), method (patient’s subjective lethality of method, objective medical lethality), consequences (medical severity, resulting treatment, psychosocial consequences), and intent (expectation of lethality of method and death, attitude toward life, feeling about discovery and survival) are important characteristics of past self-harm that should be identified during the initial assessment.[119]
current suicide plan
In general, suicide plans that are premeditated and well-thought-out involve the choice of a highly lethal method and are planned for a setting and time when discovery is unlikely. Presence of a plan of this nature should increase concern for a patient’s safety. The World Health Organization world mental health surveys (n=84,850) found that 29% people with suicidal thoughts went on to make a suicide attempt, usually within one year of onset of the thoughts. The probability of suicide increased to 56% if there was also a suicide plan (15.4% probability of a suicide attempt if they did not have a suicide plan).[122]
access to lethal means
history of psychiatric disease, including substance misuse
Mental illness is a major component of suicide, with up to 90% of people dying by suicide having a psychiatric diagnosis, most commonly major depressive disorder or substance misuse.[51][52][53]
Suicide is also associated with other mood disorders (e.g., bipolar disorder I and II, schizoaffective disorder), anxiety disorders, anorexia nervosa, and psychotic disorders.[127] Discontinuation of treatment increases risk.
family history of suicide or mental illness
Suicide or self-harm in a first-degree relative, psychiatric disorder in first-degree relative, substance misuse in the family, domestic violence/abuse, and/or high level of family conflict may raise concern if present.
Other diagnostic factors
common
chronic medical illness, disability, or disfigurement
The presence of current medical diagnoses or physical challenges such as terminal illness, chronic disease, pain, functional impairment, cognitive impairment, loss of sight or hearing, disfigurement, and loss of independence/increased dependency on others may increase thoughts of suicide.[53][65][66][67][68][69][70][71]
significant psychosocial factors
Actual or perceived interpersonal loss or bereavement, perceived humiliation, legal difficulties, financial difficulties, changes in socioeconomic status (e.g., job loss), housing problems, work/school issues, family problems, marital/relationship troubles, interpersonal/peer group problems, and domestic violence increase stress for an individual and they may think of suicide.
unhelpful traits
Poor problem-solving skills, poor insight, poor affective control, rigid thinking, dependency, and impulsivity may affect coping ability and potentially increase vulnerability to self-harm or suicide.
Risk factors
strong
current suicidal plan
In general, suicide plans that are premeditated and well thought out usually indicate an elevated risk of suicide.[42] In a sample of British psychiatric hospital inpatients, the odds of death by suicide increased 11-fold given presence of a suicide plan (odds ratio 11.8, 95% CI 1.3 to 111.3).[43] On the other hand, nondisclosure of a suicidal plan does not signify absence of risk.[44]
self-harm
Although most people who self-harm may not intend to end their life, self-harm is associated with a 50- to 100-fold increased risk of future suicide.[45] The most important predictor of future self-harm is past self-harm.[46][47] With each repetition of self-harm, suicide risk increases.[48] Continued use of weak analgesics to self-poison is a particularly strong indicator of future suicide. After a first episode of self-harm, 20% of people who attend hospital repeat self-harm within a year (many return to the same hospital).[4][49] For children and young people, the link between self-harm and suicide is greater than previously thought, and in the first year after self-harm adolescents and young adults (up to age 24 years) are at markedly increased risk of suicide, especially those who initially used violent self-harm methods.[21] The site of self-injury may also be an important determinant of risk of subsequent suicide.[50]
history of mental illness, including substance misuse
Up to 90% of people who die by suicide have a psychiatric diagnosis, most commonly major depressive disorder and substance misuse (both alcohol and illicit substances).[51][52][53] In young people, the relationship between mental illness and suicide is less strong, with only the minority of young people who die by suicide having a diagnosed mental illness. However, all diagnoses of a mental illness carry a risk.[51] Recent use of alcohol in the general population is associated with a significantly increased suicide risk. The risk increases relative to the amount of alcohol consumed.[54]
availability of lethal means
Access to lethal means significantly increases risk for death by suicide. The retrospective US national mortality survey showed that the odds of suicide increased 28-fold given the presence of a firearm in the home (odds ratio 27.9, 95% CI 18.7 to 41.4).[55] The most lethal means of suicide are firearms, with case-fatality rates of about 90%, followed by hanging, and suffocation.[56] Drug overdose and cutting are less lethal, with case-fatality rates of 2% and 3%, respectively.[56]
history of childhood abuse or neglect
One retrospective cohort study found that the odds of a lifetime history of attempted suicide tripled among patients who reported childhood sexual or physical abuse (odds ratio [OR] 3.4, 95% CI 2.9 to 4.0).[57] One meta-analysis of long-term health consequences of child physical abuse, emotional abuse, and neglect reported similar increased risk for suicide attempt (physical abuse [OR = 3.40; 95% CI 2.17 to 5.32], emotional abuse [OR = 3.37; 95% CI 2.44 to 4.67], and neglect [OR = 1.95; 95% CI 1.13 to 3.37]).[58]
Emotional abuse in childhood appears to convey a particularly high risk of self-harm in later life.[59]
family history of death by suicide
History of suicide attempt or death by suicide of a parent has been associated with a nearly twofold increased risk of death by suicide in offspring.[60] One Danish case-control study demonstrated increased suicide risk for patients with a family history of death by suicide (odds ratio 2.58, 95% CI 1.84 to 3.61).[61] Familiality of suicide attempts appears to be explained by a history of mental disorders among those with suicide attempts.[62]
male sex
Death by suicide is usually more common among males than among females. However, the rate of lifetime self-harm episodes by women outnumbers the rate in men.[20] Males are less likely to disclose the extent of their distress and seek health care less often for emotional distress.[63] Death by suicide is usually more common among males than females. In 2019, the suicide rate among males in the US was 34 times the rate for females.[12] However, the rate of lifetime suicide attempts among women outnumbers the rate among men.[20]
The discrepancy between males and females, with respect to death by suicide, may result from method choice because men tend to choose more lethal methods such as firearms and hanging, rather than poisoning or cutting, which are favored by women.[20] In addition, the higher rate of female suicide attempts may, in part, be due to self-harm behaviors (more common among females) being coded as suicide attempts.
prison inmate
Suicide is frequently reported as the most common cause of death in judicial settings. As a group, inmates have higher suicide rates than their community counterparts. One systematic review of risk factors for suicide in prisoners identified occupation of a single cell, recent suicidal ideation, history of attempted suicide, psychiatric diagnosis, and history of alcohol use problems as most important.[29] In addition, the International Association for Suicide Prevention Task Force on Suicide in Prisons reports that suicide risk among pretrial inmates is associated with male sex; young age (20-25 years); unmarried status; being a first-time offender arrested for a minor, usually substance-related offense; and intoxication at the time of arrest.[64] In sentenced prisoners, factors associated with suicide include older age (30-35 years), violent offence, having served considerable time in custody (often 4 or 5 years), conflict within the institution or family, a break up, or a negative outcome relating to their legal status.[64]
weak
family history of psychiatric illness
physical illness
Increased rates of suicide have been reported after neurosurgery and in medical diagnoses or physical challenges such as neurodegenerative disease, epilepsy, unspecified organic mental disorders, terminal illness, cancer, pain, asthma, type 1 diabetes mellitus, functional impairment, cognitive impairment, loss of sight or hearing, disfigurement including chronic skin conditions, and loss of independence or increased dependency on others.[53][65][66][67][68][69][70][71] All physical disorders, especially those which are chronic or degenerative in nature, or which disturb sleep, increase the risk of suicide.[53][66][72]
marital status (divorced, single, widowed)
One US-based national longitudinal mortality study demonstrated an increased risk for suicide among divorcees, especially men (relative risk 2.47, 95% CI 1.84 to 3.30).[73] One Italian study concluded that being single, divorced, or separated was associated with a higher rate of suicide (odds ratio 2.00, 95% CI 1.87 to 2.16).[74] Married women are at highest risk for suicide in some developing countries, whereas in developed countries suicide risk is higher for divorced, widowed, or separated men.[18]
professions/occupations (unemployed, self-employed, agricultural workers, medical and dental professionals)
In general, the lowest-skilled occupations are probably at greater risk of suicide than the highest skill-level group,[75] and unemployed people tend to have a higher suicide rate than those in the workforce.[76] One New Zealand study found that people working in farming, fisheries, forestry, and trades had higher suicide rates than people in other occupations.[76] Studies from England and Wales have historically pointed to medical and dental professionals in addition to agricultural occupations. Farmers in India have a particularly high risk of suicide.[77] One Danish study found that suicide risk was reduced in all occupations after adjustment for history of psychiatric admission and socioeconomic factors (employment status, marital status, gross income), with the exception of medical doctors and nurses.[78]
Higher social classes tend to have a lower suicide rate than lower socioeconomic classes.[75] Additionally, unemployment and underemployment have also been linked to increased suicide mortality.[79]
psychosocial stressors
Suicide risk factors associated with psychosocial history include actual/perceived interpersonal loss or bereavement, perceived humiliation, legal difficulties, financial difficulties, changes in socioeconomic status (e.g., job loss), housing problems, work/school issues, family problems, marital/relationship troubles, interpersonal/peer group problems, and domestic violence. In older adults, loneliness, mistreatment, and lack of social support appear to increase the risk of suicide.[80] Social disadvantage, nonintact family of origin, parental psychopathology, and history of childhood physical or sexual abuse have also been studied as risk factors for suicide, especially in youth.[81][82][83] In low- and middle-income countries, the presence of poverty (e.g., diminished wealth and unemployment) is positively correlated with suicidal thoughts and self-harm.[84]
There is emerging evidence that recent bereavement may increase risk, especially in young people.[14][85][86]
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