of self-harming behaviors (Clements-Nolle, Lensch, Yang, Martin, Peek, & Yang, 2020). Additionally, it appears that suicide tends to run in families, and it has been estimated that social environment and genetic factors play about an equal role in determining who engages in suicidal behaviors (Lin & Tsai, 2016). Other family dysfunction factors linked to suicidal behavior include parental separation or divorce, presence of psychiatric diagnoses in other family members, domestic violence, and displacement (e.g., temporary living situations vs. stable ones; Clements-Nolle et al., 2020; Marshall, Semovski, & Stewart, 2020; Miranda-Mendizzbal et al., 2019). Romantic relationships and divorce Difficulties in romantic relationships can be a contributing or even a potentiating factor for suicidal behavior. Dating violence in young women, for example, has been connected to suicide risk (Miranda-Mendizzbal et al., 2019). Non- married and especially divorced status are predictive Potentiating factors 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 suicide methods and/or plans, and contemplation about planning for one’s death (Klonsky, May, & Saffer, 2016). The 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. 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 High-risk populations In addition to the prior risk factors, there are certain populations who are known to be at increased risk for death by suicide, including: sexual and gender minority populations, older adults (65 and older), veterans, and individuals in jail or recently released. Sexual and gender minority populations Individuals who identify as sexual minorities (e.g., individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, asexual or those questioning their orientation; LGBTQIA) face a number of unique challenges and stressors, and these stressors have often translated into elevated rates of suicidal behavior for both adults (Chang, Fehling, & Selby, 2020) and adolescents (Chang, Kellerman, Feinstein, Selby, & Goldbach, 2020). Youth and young adult suicide rates can reach as high as 20% among LGBTQIA groups and as high as 41% in transgender groups (Turban, Beckwith, Reisner, et al., 2019), making assessment and intervention for suicide concerns essential for these high-risk individuals.
of suicide among men and, to a lesser degree, women (Kyung-Sook, SangSoo, Sangjin, & Young-Jeon, 2018). As will be seen in subsequent discussion of theoretical models of suicide, romantic relationships represent one of the most important interpersonal relationships an individual can have, and problems in this area can substantially weaken interpersonal connections that buffer against suicide risk. Domestic violence Women experiencing turbulent relationships are also at increased risk for suicide, especially when the relationship is characterized by domestic violence and in cases where the partner is exhibiting addiction, coercion, physical assault, jealousy, infidelity, or threatening divorce (Rahmani, Salmasi, Rahmani, Bird, Asghari, et al., 2019). Patients indicating the presence of domestic violence in their home should be carefully screened for suicide risk in addition to addressing personal safety concerns. 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. 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, more than 50% of deaths by suicide involve utilizing a firearm (Khazem & Anestis, 2016). Indeed, the presence of a gun in the home is one of the strongest predictors differentiating those who died by suicide from other suicidal individuals 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. Senior populations Suicide is a significant problem among older adults. Suicide rates are particularly high among older men; according to the Suicide Prevention Resource Center (SPRC), men 65 and older have the highest rate of any group in the country (SPRC, 2018b; Sheava, Hitching, & Dunn, 2019). Suicide attempts by older adults are much more likely to result in death than attempts by younger persons. Reasons for this may be that: older adults plan more carefully and use more deadly methods; older adults are less likely to be discovered and rescued; or the physical frailty of older adults means they are less likely to recover from an attempt. Risk factors for this population include depression and other mental health problems; substance use problems (including prescription medications); physical illness, disability, and pain; and social isolation. Protective factors include care for mental and physical health problems, social connectedness, and skills in coping with and adapting to change.
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