This document discusses suicide, including definitions, risk factors, clinical presentation, assessment, epidemiology, and management. Key points include: - Suicide is defined as self-inflicted death with intent to die, while a suicide attempt is a non-fatal self-injurious behavior with intent. Risk of future attempts is highest for those with a past attempt in the past year. - Suicide risk should be assessed in every patient encounter by asking about thoughts of harming oneself and evaluating ideation, plan, intent, past attempts, and other risk factors. - High-risk patients with a plan and means to act on it should be strongly considered for hospitalization, while lower-risk patients can be

1. Suicide
Dr. Mark Mohan Kaggwa

3. • Suicide is defined as self inflicted death with evidence that the person intended
to die.
• Suicide attempt self injurious behavior with a nonfatal outcome and evidence
that the person intended to die Aborted suicide attempt-potentially self injurious
behavior with evidence that the person intended to die but stopped before
physical damage occurred
• Suicide ideation thoughts of serving as the agent of one’s own death
• Suicidal intent subjective expectation and desire for self-destructive act to end in
death
• Lethality objective danger to life associated with suicide action or method
• Deliberate self harm willful self-infliction of painful, destructive or injurious acts
without intent to die

4. Suicide
Importance
• must be screened for in every encounter; part of risk assessment along with
violent/homicidal ideation
Approach
• ask every patient – e.g. “Have you had any thoughts of wanting to harm or kill
yourself?”
• classify ideation
• passive ideation: would rather not be alive but has no active plan for suicide e.g. “I’d rather
not wake up” or “I would not mind if a car hit me”
• active ideation e.g. “I think about killing myself”
• assess risk
• plan: “Do you have a plan as to how you would end your life?”
• intent: “Do you think you would actually carry out this plan?” “If not, why not?”
• past attempts: highest risk if previous attempt in past year
• ask about lethality, outcome, medical intervention

5. • assess suicidal ideation
• onset and frequency of thoughts: “When did this start?” or “How often do you have these
thoughts?”
• control over suicidal ideation: “How do you cope when you have these thoughts?” “Could
you call someone for help?”
• intention: “Do you want to end your life?” or “Do you wish to kill yourself?”
• intended lethality: “What do you think would happen if you actually took those pills?”
• access to means: “How will you get a gun?” or “Which bridge do you think you would go
to?”
• time and place: “Have you picked a date and place? Is it in an isolated location?”
• provocative factors: “What makes you feel worse (e.g. being alone)?”
• protective factors: “What keeps you alive (e.g. friends, family, pets, faith, therapist)?”
• final arrangements: “Have you written a suicide note? Made a will? Given away your
belongings?”
• practiced suicide or aborted attempts: “Have you ever put the gun to your head?” “Held
the mediations in your hand?” “Stood at the bridge?”
• ambivalence: “I wonder if there is a part of you that wants to live, given that you came
here for help”

6. Assessment of Suicide Attempt
• setting (isolated vs. others present/chance of discovery)
• planned vs. impulsive attempt, triggers/stressors
• substance use/intoxication
• medical attention (brought in by another person vs. brought in by self to ED)
• time lag from suicide attempt to ED arrival
• expectation of lethality, dying
• reaction to survival (guilt/remorse vs. disappointment/self-blame)

7. Epidemiology
• attempted: completed = 20:1
• M:F = 1:4 for attempts, 3:1 for completed
Risk Factors
epidemiologic factors
• age: increases after age 14, second most common cause of death for ages 15-24,
highest rates of completion in persons >65 yr
• sex: male
• race/ethnic background: white.
• marital status: widowed/divorced
• living situation: alone; no children <18 yr old in the household
• other: stressful life events, access to firearms

8. psychiatric disorders
• mood disorders (15% lifetime risk in depression; higher in bipolar)
• anxiety disorders (especially panic disorder)
• schizophrenia (10-15% risk)
• substance abuse (especially alcohol – 15% lifetime risk)
• eating disorders (5% lifetime risk)
• adjustment disorder
• conduct disorder
• personality disorders (borderline, antisocial)
past history
• prior suicide attempt
• family history of suicide attempt/completion

9. Clinical Presentation
symptoms associated with suicide
• hopelessness
• anhedonia
• insomnia
• severe anxiety
• impaired concentration
• psychomotor agitation
• panic attacks

10. Management
• proper documentation of the clinical encounter and rationale for management is
essential
• higher risk (hospitalization needs to be strongly considered)
• patients with a plan and intention to act on the plan, access to lethal means, recent social
stressors, and symptoms suggestive of a psychiatric disorder
• do not leave patient alone; remove potentially dangerous objects from room
• if patient refuses to be hospitalized, complete form for involuntary admission (Form 1)
• lower risk
• patients who are not actively suicidal, with no plan or access to lethal means
• discuss protective factors and supports in their life, remind them of what they live for
promote survival skills that helped them through previous suicide attempts
• make a safety plan that could include an agreement that they will:
• not harm themselves
• avoid alcohol, drugs, and situations that may trigger suicidal thoughts
• follow-up with you at a designated time
• contact a health care worker, call a crisis line, or go to an emergency department if they feel unsafe or if
their suicidal feelings return or intensify

11. • depression: consider hospitalization if symptoms severe or if psychotic features
are present; otherwise outpatient treatment with good supports and SSRIs/SNRIs
• alcohol-related: usually resolves with abstinence for a few days; if not, suspect
depression
• personality disorders: crisis intervention, may or may not hospitalize
• schizophrenia/psychosis: hospitalization might be necessary
• parasuicide/self-mutilation: long-term psychotherapy with brief crisis
intervention when necessary