Suicide Assessment and Prevention _ ____________________________________________________________
Patient A is transferred to a regular floor and a sitter is assigned to her room. With the aid of additional clinical observation and consul- tations, a clearer picture emerges. In the presence of staff, Patient A appears open and optimistic and takes initiative; when her boyfriend or family are present, she becomes passive, more withdrawn, and demanding, expecting others to attend to her needs. Patient A’s parents divorced when she was 11 years of age, and two years later, she came under psychiatric care, followed by counseling, because of depression and a brief period of suicide ideation. She had attended college but dropped out after two years. In recent months, her life had become more chaotic. She was unhappy in her job and subject to fits of anger and despondency. She was often at odds with her live-in boyfriend, who, on occasion, threatened to leave her and in fact did so four days prior to her admission. The decision to take an overdose of her mother’s medication was judged to have been abrupt and impulsive, perhaps a “suicide gesture”—partly misdirected anger and partly designed to win back the attention of her boyfriend. Nevertheless, she almost succeeded in taking her life. The consultant’s diagnosis is borderline personality disorder and likely major depression. She is transferred to the inpatient psychiatry service for further evaluation and care. Some days later, she is discharged to a mental health clinic for psychiatric and social service follow-up combined with ongoing counseling. HEALTHCARE PROFESSIONALS Some occupations are known to have higher rates of suicide than others. Job factors, including chronic stress, vicarious trauma, low job security, and low pay, can contribute to risk of suicide, as can easy access to lethal means (e.g., medications, firearms) among people at risk. Other factors that can influ- ence the link between occupation and suicide include gender, socioeconomic status, economic environment, cultural factors, and stigma [115]. Healthcare workers have historically been at disproportionate risk of suicide, due to a variety of factors, including difficult working conditions, such as [115]: • Long work hours • Irregular shifts • Emotionally difficult situations • Risk for exposure to infectious diseases and other haz- ards on the job, including workplace violence • Routine exposure to human suffering and death (vicari- ous or secondary trauma) • Access to lethal means (e.g., medications) and knowl- edge about using them In 2019, a large review of more than 60 scientific studies was conducted to address conflicting data on the nature of suicide among healthcare workers. The researchers found that physicians were at a significant and increased risk for suicide, with female physicians at particularly high risk [116]. A cross- sectional survey involving 7,378 nurses found that nurses were at increased risk for past-year suicidal ideation (5.5%) [117]. In addition, nurses with suicidal ideation were less likely to be willing to seek help (72.6%) than nurses without suicidal
ideation (85%). Burnout was strongly associated with suicidal ideation, even after controlling for other personal and profes- sional characteristics [117].
RISK AND PROTECTIVE FACTORS FOR SUICIDE Suicide is now understood to be a multidimensional disorder stemming from a complex interaction of biologic, genetic, psychologic, sociologic, and environmental factors [59; 60]. One of the first social scientists to empirically investigate con- tributing factors to suicide was Émile Durkheim. Instead of focusing only on shared traits among persons who had died by suicide, Durkheim compared one group with another and originated the scientific study of suicide risk factors [5; 61]. Protective factors reduce suicide risk by enhancing resilience and counterbalancing risk factors, while risk factors increase the potential for suicidal behavior. Protective and risk factors may be biopsychosocial, environmental, or sociocultural in nature [5]. PROTECTIVE FACTORS Several protective factors against suicide behavior have been identified [5; 62]. These include: • Access to effective clinical care for mental, physical, and substance use disorders, and support for help-seeking • Restricted access to highly lethal means of suicide • Strong connections to family and community support • Emotionally supportive connections with medical and mental health providers • Effective problem-solving and conflict-resolution skills • Cultural and religious beliefs that discourage suicide and support self-preservation • Reality testing ability • Pregnancy, children in the home, or sense of family responsibility • Life satisfaction RISK FACTORS In addition to risk factors specific to special populations, there are many general risk factors common among most popula- tions. General biopsychosocial risk factors include [2; 5; 62]: • Psychiatric disorders • Alcohol and other substance use disorders • Hopelessness • Impulsive and/or aggressive tendencies • History of physical or sexual trauma or abuse, especially in childhood • Medical illness involving the brain or central nervous system (CNS)
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