_____________________________________________________________ Suicide Assessment and Prevention
• Consider the key issue(s) and give some thought to your clini- cal approach (e.g., sequencing the encounter and useful tools that will help to identify major depression and assess suicide risk). • Anticipate logistical barriers in relation to time of day and the possible need for immediate psychiatric consultation and/or hospitalization.
Ingestion of other toxic substances (including bleach, poisons, and agricultural chemicals), jumps from tall heights, and exsanguination are also relatively common methods of suicide attempt and completion. When assessing risk, it is important to consider the patient’s level of impulsivity and the potential lethality of available means (particularly firearms). MOTIVES BEHIND SUICIDAL BEHAVIOR Although thousands of books have explored the question of why people kill themselves, in most cases the answer can be summed up in three words: to stop pain. The pain may be physi- cal, as in chronic or terminal illness, but is usually emotional. However, Stone has delineated a more elaborate description of the motivations for suicide, including [18]: • Altruistic/heroic suicide: Occurs when someone (more or less) voluntarily dies for the benefit of the group. Examples include the Japanese kamikaze pilots in WWII and the Buddhist monks who burned them- selves to death protesting the Vietnam war. • Philosophical suicide: Various philosophical schools, such as the stoics and existentialists, have advocated suicide under some circumstances. • Religious suicide: Often as martyrdom, this type of sui- cide has a long history that spans from early Christian- ity to the Branch Davidians in Waco, Texas, and some members at Jonestown, Guyana. • Escape: This type of suicide represents an escape from an unbearable situation, such as persecution, a terminal illness, or chronic misery. • Excess alcohol and other drug use • Romantic suicide: This includes suicide pacts (dual sui- cide), which constitute about 1% of suicides in Western Europe. Participants are usually older than 51 years of age, except in Japan, where 75% of dual suicides are “lovers’ pacts.” • “Anniversary” suicide: Suicide involving the same method or date as a deceased loved one. • “Contagion” suicide: Occurs when one suicide appears to trigger others (e.g., “cluster” and “copycat” suicides), most often among adolescents. • Manipulation: Usually involving the theme “If you don’t do what I want, I’ll kill myself.” The word “manipulative” does not imply a lack of seriousness, as fatal suicide attempts can be made by people hoping to influence or manipulate the feelings of others even though they will not be around to witness the outcome. However, the intent of manipulative attempts is to produce guilt in the other person, and a nonfatal result is usually intended. • Call for help: An expression of unbearable pain and misery that is more frequent in the young.
SUICIDE ATTEMPTS
LETHAL MEANS In the United States in 2019, use of a firearm was the cause of death in 50.4% of suicides and is the number one means among all individuals 15 years of age and older. Gun use accounts for 47% of all suicide deaths in individuals 15 to 24 years of age, reaching a low of 42.1% in those 35 to 44 years of age, and increasing to 51.8% in those 55 to 64 years of age. Firearm use for suicide completion is extremely high among the elderly, with individuals 75 to 84 and 85 years of age and older having the highest rates, at 75.4% and 76.6%, respectively. Gun use is also the most common suicide method among youth, accounting for 31.5% of all suicide deaths [1; 78]. Although most gun owners report keeping a firearm in their home for the purpose of protection or self-defense, 83% of gun- related deaths in these homes are the result of a suicide, usually by someone other than the gun owner. Guns are involved in more deaths by suicide than by homicide, and overall, death by firearm is the most common suicide method [12]. The suicide rates among youths 15 to 24 years of age by firearm increased from 5.3 per 100,000 in 2001 to 6.6 per 100,000 in 2019, while the suicide rates by suffocation (e.g., hanging) increased from 3.1 per 100,000 in 2001 to 5.0 per 100,000 in 2019. These trends among teens and young adults have been mirrored by children 5 to 14 years of age, in whom deaths by firearms and suffocation have been increasing since at least 2001 [1; 78]. The most common method of suicide death among women in all age groups from 2001 to 2019 was poisoning (35.5%); however, in 2018, firearms surpassed poisoning for the first time since 2000 among female victims [15; 78]. Although intentional overdose is the most common method for suicide attempts in women, it is much less likely to result in death. Many over-the-counter medications, prescription drugs, dietary supplements/herbal medications, or illicit drugs may be used to attempt suicide. Ibuprofen is a popular over-the-counter anal- gesic and a common drug of choice in intentional overdoses. There were more than 12,490 intentional overdose ingestions of ibuprofen reported by U.S. poison control centers in 2018, resulting in one death [89]. Opioid analgesics result in many deaths due to intentional overdose. In one study, researchers found that the percentage of individuals who died by suicide and had opioids in their system more than doubled, from 8.8% to 17.7%, between 2006 and 2017 [45].
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