Behaviorial risk factors Prior suicide attempts
Access to lethal means Access to means to enable a suicide attempt is a particularly troubling risk factor for suicide, especially among men (Miranda- Mendizzbal et al., 2019). In the United States, access to firearms frequently is implicated as a proximal factor in the completion of suicide. Indeed, the presence of a gun in the home is one of the strongest predictors differentiating youth who died by suicide from other suicidal youth who attempt but survive suicide (Knopov, Sherman, Raifman, Larson, & Siegel, 2019; Santaella- Tenorio, Cerdá, Villaveces, & Galea, 2016). Firearms simply are a very lethal suicide attempt method. This lethality is aided by the quickness and extent of physical trauma that firearms can deliver. All suicide assessments should include questions about the availability of firearms (Khazem & Anestis, 2016). Contrary to interviewers’ concerns, patients are likely to adhere to advice about gun removal, and legislation that reduces access to guns is related to lower suicide rates (Houtsma et al., 2018; Anestis et al., 2015). If the patient does have firearms at home, the assessing clinician should advise him or her to remove the ability to access the guns. Non-suicidal self-injury As has previously been discussed, NSSI is highly associated with risk for future suicidal behavior (Kiekens et al., 2018) and is as strong a predictor of future suicide attempts, as are previous suicide attempts themselves (Ribeiro et al., 2016). Presence of this behavior should be carefully examined to determine if suicide risk is present, and NSSI should be treated to prevent potential subsequent suicidal behavior. more intense and frequent suicidal ideation becomes on a daily basis, the greater the need for clinical concern. However, although suicidal ideation is present in the majority of cases of suicidal behavior, suicidal ideation is a non-specific risk factor for suicide, and it is not predictive of imminent suicide risk. Indeed, to date, no studies have found that asking someone about current suicidal ideation is predictive of a suicide attempt in the very near future (Franklin et al., 2016). Accordingly, presence of suicidal ideation should also indicate the need for further suicide risk assessment, however, suicidal ideation in the absence of other risk factors is unlikely to indicate imminent suicide risk. Nonetheless, safety precautions in the presence of suicidal ideation should always be taken. Substance use The connection between heavy substance use and suicidal behavior has long been a subject of investigation, with questions arising as to whether the substance drives the individual toward suicidal behavior, or whether the substance is used as a way of coping with the suicidal behavior (Chesin, Interian, Kline, Hill, et al., 2019). Recent meta-analytic studies have identified substance use as a major predictor of suicidal behavior, with the odds of suicide increasing seven-fold among substance users relative to those refraining from substance use (Conner, Bridge, Davidson, Pilcher, & Brent, 2019). For example, alcohol use increases the proximal risk for suicidal behavior because of its ability to increase psychological distress and aggressiveness, push suicidal ideation into action through suicide-specific alcohol expectancies, and limit cognition, which in turn impairs the creation and implementation of alternative coping strategies (Borges, Bagge, Cherpitel, Conner, et al., 2017). Because of the clear link between a variety of substance use disorders and suicide, any acute changes in substance use behavior should be examined in connection to potential increases in suicide risk. Difficulties in problem solving Deficits in problem-solving skills have also been reported in suicidal youth (Gutierrez & Osman, 2008). Challenges with understanding emotions, responding to emotions in an adaptive manner, and regulating impulsive behaviors have also been found to predict both short- and long-term increases in suicidal ideation (McHugh, Lee, Hermens, Corderoy, Large, et al., 2019).
Approximately half of individuals who die by suicide do so after a single attempt (Franklin et al., 2016), which means that about 50% of individuals will die on their first attempt. A recent study on risk factors for death by suicide concluded that prior attempts and suicidal ideation were the best predictors of completed suicide (Ribeiro et al., 2016). However, it should be noted that prior attempts and suicidal ideation were relatively weak predictors, as they only increased risk for later death by suicide two-fold. Some research suggests that people who make multiple attempts (i.e., two or more) are at greater risk for further suicide attempts and completion than people who have made only one attempt (Defayette, Adams, Whitmyre, Williams, & Esposito-Smythers, 2020). Additionally, research suggests that, among attempters, the greatest risk for a subsequent attempt is in the 6 months to 2 years following the attempt (Franklin et al., 2016). Clearly, clinicians should take note of any history of prior attempts, as well as the timing of the behavior, in order to better assess risk status. Suicide plans and preparations Common behaviors under the umbrella of suicide plans include giving away possessions, writing notes, acquiring weapons or other items that will facilitate a suicidal act. A patient acknowledging the presence of suicidal planning and preparing is known to be one of the strongest risk factors for suicidal behavior (Marie et al., 2020) and should be taken very seriously, as will be discussed in the upcoming section on suicide risk assessment. Psychosocial distal risk factors for suicide can include childhood physical and/or sexual abuse, neglect, emotional abuse, family members with psychiatric disorders, a family history of suicide, and family violence (Clements-Nolle et al., 2020; Ng, Yong, Ho, Lim, & Yeo, 2018; Zatti, Rosa, Barros, Valdivia, Calegaro, et al., 2017). Psychiatric diagnoses As has been previously discussed, aside from past suicide attempts, psychopathology is the most important predictor of suicide and is strongly associated with other forms of suicidal behavior. The vast majority (90 to 95%) of individuals who die by suicide have some diagnosable disorder at the time of death (Choi, Lee, & Han, 2020); it is likely that the fraction who did not were experiencing subclinical levels of psychopathology. Although most mental illnesses increase risk for death by suicide (APA, 2013), there are several disorders that are associated with particularly high risk. These include schizophrenia (approximately 13-fold increase in risk; Cassidy, Yang, Kapczinski, & Passos, 2018), anorexia nervosa (up to a 31-fold increase in risk; Selby & Coniglio, 2020), bipolar disorder (approximately 17-fold increase in risk; Olfson et al., 2016), major depressive disorder (approximately 20-fold increase in risk); Olfson et al., 2016), impulse-control disorders such as opioid use (approximately 14-fold increase in risk; Maruti et al., 2017), and personality disorders, especially borderline personality disorder (up to a 45-fold increase in risk; Soloff & Chiappetta, 2019). Retrospective interviews with informants, commonly referred to as psychological autopsies, have frequently been used to investigate the association between psychopathology and suicide and have consistently shown that roughly 90% of individuals who die by suicide had an identifiable psychiatric disorder before death (Perlis et al., 2016). Suicidal ideation Suicidal ideation is an important risk factor in the detection of potential suicidal behavior, and involves increased thoughts about and potential desires for death, active thoughts about harming oneself or taking one’s life, consideration of potential Psychological risk factors Psychosocial distal risk factors suicide methods and/or plans, and contemplation about planning for one’s death (Klonsky, May, & Saffer, 2016). The
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