1. Understanding Suicide Risk Factors A Guide for Suicide Prevention Workers

2. This guideline is excerpted from sources believed to be authoritative and accurate. Because of the complex and often difficult nature of the subject, workers in the suicide-prevention field should avail themselves of all available resources and information, and should not rely solely on this, or any other general guide in their work. This guide is not intended to suggest treatment approaches or protocols, nor a model upon which to base a standard of care. Ultimate diagnosis and treatment of suicidal or potentially patients must be made by competent clinicians and other appropriate personnel, based on the best possible data presented by the patient, and from other sources.

3. Disorders Correlated With Suicide  The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) of the American Psychiatric Association describes five disorders that are correlated with suicidal behavior. These disorders include: –Mood Disorders –Panic Disorder –Schizophrenia –Alcoholism –Borderline Personality Disorder  Other factors, including age-specific factors, have also been identified that correlate with suicidal behaviors

4. Disorders Associated with Suicide  1. Mood Disorders –Patients suffering mood disorders have up to a 15% lifetime risk of suicide.  Common Manifestations: –Panic Attacks –Alcohol Abuse –Increased hopelessness –Psychic Anxiety –Loss of joy and pleasure (anhedonia) –History of suicide attempts  2. Panic Disorder –Panic disorder patients have a 7-15% lifetime risk of suicide.  Considerations: –Suicide may occur at time other than during panic attack –Agitation is believed to increase likelihood of suicidal action –More severe illness or presence of another disorder increase likelihood of suicide –Loss and demoralization increase likelihood

5. Disorders Associated with Suicide  3. Schizophrenia –Schizophrenia patients have about a 10% lifetime risk of suicide.  Considerations: –Attempts do not usually occur during psychotic episodes. –60-80% of schizophrenics have significant thoughts of suicide, up to 55% attempt suicide –Command hallucinations (“inner voices”) have not been found to be clearly related to suicide attempts.  4. Alcoholism/Drug Abuse –Can often be attempt to self- medicate for mood or psychiatric disorder –Increased potential for suicide found with:  Adolescence  Ongoing abuse, especially after 20+ years of abuse  Actual or anticipated interpersonal loss

6. Disorders Associated with Suicide  5. Borderline Personality Disorder –BDP patients have approximately 7% lifetime risk of suicide  Increased BDP factors: –Impulsivity, despair, hopelessness –Antisocial-dishonest behavior –Self-mutilation –Psychotic episodes that include grandiose or bizarre suicide attempts.

7. Who is Most Likely to Commit Suicide?  90% or more completed suicides come from 3 main diagnosed conditions: –Alcoholism (associated with 50% of all suicides) –Depression –Schizophrenia –Combinations of these conditions.  Male  Over 75 years of age

8. Other Factors Associated with Suicide  In addition to the five disorders just presented, the following factors are often associated with increased risk of suicide: –Interpersonal and family psychopathology, including crises and life stresses –Other personality disorders and characteristics –Physical illness, especially if painful, also delirium associated with illness –Availability of effective means of suicide, such as drugs and firearms –Prior family history of mental illness and/or suicide

9. Evaluating the Patient’s State  Physiological, Cognitive, Emotional –Is the patient hopeless? –Is the patient depressed or despairing? –Is the patient able to act? –Does the patient experience physical pain, interpersonal loss, is the patient intoxicated? –Does the patient suffer from chronic drug/alcohol abuse? –Does the patient feel strong emotional stressors such as shame, panic, rage, self- loathing, acute loneliness?

10. What are the Patient’s Expectations of Suicide?  Does the patient simply wish to die, or are other goals anticipated such as punishment of others, escape, self-punishment?  Spiritual/religious views, such as wish for rebirth or reunion with dead loved one; does patient have a positive connotation of death?  Has the patient lost a fundamental relationship or lost his/her primary reason for living?  What form does the patient wish for the suicide to take?

11. Evaluating the Patient’s Intent  How often does the patient have suicidal thoughts or feelings? Can s/he describe them?  Does the patient consciously think of suicide, or do thoughts/feelings come unbidden?  Can the patient control the thoughts, or are they obsessive and persistent?

12. Planning and Lethality  Has the patient planned or rehearsed any suicide scenario?  Is there a specific place and time involved?  What means does the patient intend to use to kill him/herself? Do they now have access to this or will they have to obtain it?  What are the expectations? Certain death; self- injury, rescue, “payback”, or another outcome?  Has the patient completed any of the “steps”, such as giving away property, attending to financial affairs, obtaining weapons or drugs, etc?

13. Is There a History of Self-Destructive Behavior?  Self-mutilation is often a self-soothing behavior, and not necessarily a suicide attempt. Some self-mutilators do, however, go on to commit suicide.  Have there been previous suicide attempts? If so, can the patient describe the circumstances and motivators, and how they compare with current feelings and motivators?  Lack of previous attempts does NOT rule out risk of a current attempt.

14. Relationship of Prior Attempts to Completed Suicides  A prior attempter has a 7-10% increased risk over the general population of completed suicide  18%-38% of suicide deaths (completed suicides) made a prior suicide attempt  90% of attempters do not complete a suicide  1% of past attempters complete suicide each year.

15. Assessing the Patient’s Coping Ability  Has the patient suffered a recent stressor such as failure, humiliation or loss, either actual, imagined, or anticipated?  Has the patient suffered loss of any element of his/her support system?  Is the patient capable of self-regulation?  Does the patient have a history of impulsive behavior?  Is the patient self-actualized, or need external support to maintain self esteem, if so, are there external resources available?  Is the patient able to realistically contract to constructively participate in his/her treatment plan?

16. Age-Related Risk Factors  Under 30 Years –Family history of suicide –Males oftener than females –Firearms availability –Peer influence in area –Prior attempts –Native American –Psychiatric diagnosis of mood disorders; substance abuse –Whites oftener than blacks –History of delinquent behavior  Over 30 Years –Over 75 years of age –Loss of social supports –Singles, especially separated, widowed, divorced. –Native American –Prior attempts –Multiple medical illnesses –Males oftener than females –Family history of suicide –Psychiatric diagnosis of mood disorders; schizophrenia, alcoholism –Unemployment –Psychological turmoil

17. Summary  Ability to recognize and evaluate a patient’s suicidality can be enhanced by understanding increased risk factors including: –Five DSM-IV disorders that correlate to suicidal behaviors –Additional factors that alone, or in conjunction with the DSM-IV factors, can increase suicide risk –A patient’s age, coping ability, history, suicide planning, intent, expectations, and physiological, cognitive, and emotional states.