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Suicidal Intent: Expectation and desire for a self-injurious act to end in death. Suicidal Plan: Plan of the method, means, time, place, or other details for engaging in self-inflicted injurious behavior with any intent to die because of the behavior. Suicidal Thoughts: General nonspecific thoughts of wanting to end one’s life. Suicide: Death caused by intentional self- directed injurious behavior with any intent to die. Suicide Attempt: A non-fatal, self-directed, potentially injurious behavior with any intent to die because of the behavior with or without injuries. Healthcare Professional Consideration: Healthcare professionals need to talk about suicide in a non-judgmental way and avoid stigmatizing terms. Hopefully, learning how to talk about suicide can encourage people to seek help.
Introduction
Suicide Terminology
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The U.S. Centers for Disease Control [CDC] (2019) has identified suicide as one of the top ten leading causes of death in the 10-65 age group. According to the Suicide Prevention Resource Center (SPRC), suicide acts take a tremendous emotional and economic toll on the families and loved ones of those who engage in suicidal behaviors. Not only does the suicidal behavior of a loved one cause an emotional toll on family members and place others within the family unit at risk of dying by suicide, but it also results in increased medical costs for individuals and families, lost income for families, and lost productivity for employers and the community. This topic must be addressed throughout the healthcare community to prevent further avoidable loss of life. 1 The financial benefits of implementing suicide preventative measures will, hopefully, convince policymakers and lawmakers that suicide prevention is not only the “right” thing to do, morally speaking, but is also an investment that has a financial benefit in addition to saving lives. A recent study by Shepard et al., in 2015 found that the total cost of suicide acts in 2013 was $93.5 billion, with an estimated average cost of $1,329,553 for a single suicide. Approximately 97% of this cost was attributed to lost wages from productivity, whereas the remaining 3% went to medical treatment. The study also estimated that every $1 spent on psychotherapeutic interventions and interventions that promoted linkages between different care providers saved $2.50 in suicides. 1 Primary care providers may be able to prevent suicide due to their frequent interactions with suicidal patients. According to Schreiber and Culpepper, 2 80% of individuals who die by suicide have had at least one contact with their primary healthcare provider within one year of suicide, whereas only 25 to 30% had contact with a mental health professional within that same period. And although it cannot be determined that routine screening for suicide has prevented any death, one behavioral healthcare program saw a 65% reduction in suicide rates 20 months after implementing a routine screening protocol. 3 Nevertheless, primary care providers are more likely to see patients experiencing suicidality than mental health professionals. A screening approach sensitive to risk factors, current stressors, and the presence of ideation, plan, intent, and preparatory behaviors, especially for patients experiencing depression, may alert providers to patients who may be at acute risk for suicide. 2 Lastly, individuals discharged from a psychiatric facility have a suicide rate 300 times higher in the first week and 200 times higher in the first month compared to the general population. 4 Medical and allied healthcare professionals in emergency, behavioral health, and primary care settings thus, have a critical role in identifying patients at elevated suicide risk.
In recent years, the societal vernacular on suicide has changed. Clinicians and researchers are encouraged not to say that an individual “tried to commit suicide” or “committed suicide” because the word “commit” has negative connotations. Instead of “committed” or “completed,” it is currently recommended to use the phrase “died by suicide”. Furthermore, suicide attempts are no longer categorized as “failed,” “unsuccessful,” or “successful.” 5 The following definitions are adapted from the CDC, and the American Psychiatric Association’s Practice Guidelines for the Psychiatric Evaluation of Adults: 5 •
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Aborted or self-interrupted attempt: When a person begins to make steps towards making a suicide attempt but stops before the actual act. Affected by Suicide: All those who feel the impact of suicidal behaviors, including those bereaved by suicide, friends, community, or the actions of celebrities. Bereaved by Suicide: Family members, friends, co-workers, others affected by the suicide of a loved one. They can also be referred to as survivors of suicide loss. Interrupted Attempt: When a person is interrupted from carrying out a self- destructive act by another person or outside circumstances. Means/Methods: The instrument, material, or method used to engage in self-inflicted injurious behavior. Non-Suicidal Self Injury (NSSI): The intentional injury of one’s own body tissue without suicidal intent and for purposes not socially sanctioned, such as carving, cutting, or burning oneself, banging or punching objects or oneself, and embedding objects under the skin. Protective Factors: Factors that reduce the likelihood that an individual will engage in suicidal behavior. Risk Factors: Factors that increase the likelihood that an individual will engage in suicidal behaviors. Safety Plan: A collaborative plan between patient and clinician that contains a written list of warning signs, coping responses, supports, and emergency contacts that an individual may use to avert thoughts, feelings, or impulses or behaviors related to suicide. Suicidal Behaviors or Preparatory Actions: Acts or preparation toward making a suicide attempt that includes any evidence of intent to die. Suicidal Ideation: Thoughts of engaging in suicidal behaviors or serving as the agent of one’s own death (active ideation), or preoccupation with death or being dead (passive ideation).
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Myths about Suicide
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In society, there are many myths surrounding suicide that may prevent people from getting the help they need. Addressing common myths associated with suicide can help clinicians, researchers and the general population understand the importance of helping others address their mental health challenges by seeking treatment (see Table 1 on the next page). Healthcare Professional Consideration: Be prepared to hear suicide myths from patients or the general public. Addressing common myths surrounding suicide can help patients and others realize the importance of seeking treatment to address their mental health challenges.
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Epidemiology
Global Suicide Data The World Health Organization (WHO) recognizes suicide as a top health priority globally. However, it is estimated that more than 700,000 people die by suicide every year in the world. Suicide is the fourth leading cause of death among 15–29-year-olds globally in 2019. Given the sensitivity of suicide and the illegality of suicidal behavior in some countries, there is likely underreporting and misclassifications of deaths, making the availability and quality of suicide data poor. 7 Suicide does not just occur in high-income countries but is a global phenomenon in all regions. Over 77% of suicides occurred in low and middle- income countries in 2019. Approximately 20% of global suicides result from self-poisoning with pesticides, most of which occur in low and middle- income countries. Other top methods are hanging and firearms. 7
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