Suicide Assessment and Prevention

Course #96440 - $24 • 6 Hours/Credits


Study Points

  1. Review the epidemiology of suicide.
  2. Describe the impact of suicide in the treatment of special populations, including among military veterans.
  3. Identify risk and protective factors for suicide.
  4. Discuss warning signs of imminent suicide and the importance of lethal means.
  5. Evaluate tools available for the assessment and evaluation of suicide risk.
  6. Outline key components of an effective suicide prevention plan.

    1 . The only country in which the female suicide rate exceeds the male rate is
    A) Cuba.
    B) China.
    C) Russia.
    D) the United States.

    EPIDEMIOLOGY OF SUICIDE

    Suicide rates vary according to race, ethnicity, sex, and many other factors, including age [8]. In almost every country, suicide is predominated by male victims, with the exception of China, which is the only country in which the female suicide rate (14.8 per 100,000) exceeds the male rate (13 per 100,000) [9]. In the United States, the number of completed suicides is nearly four times greater among men (33,113) than among women (9,660). Overall, suicide accounts for 1.6% of all deaths in the United States [1].

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    2 . Most adolescent suicides occur at
    A) school after hours.
    B) the residence of a friend.
    C) home after school hours.
    D) the residence of a relative.

    SUICIDE AND SPECIAL POPULATIONS

    Most adolescent suicides occur at home after school hours. Adolescent nonfatal suicide attempters are typically girls who ingest pills, while suicide completers are typically boys who die from gunshot wounds. Intentional self-harm should be considered serious and in need of further evaluation because not all adolescent attempters admit their intent. Most adolescent suicide attempts are triggered by interpersonal conflicts and are motivated by the desire to change the behavior or attitude of others. Repeat attempters may use this behavior as a coping mechanism for stress and tend to exhibit more chronic symptomatology, worse coping histories, and higher rates of suicidal and substance abuse behaviors in their family histories [13]. The presence of multiple emotional, behavioral, and/or cognitive problems may be a more important predictor of suicide behavior risk than a specific type of problem (e.g., an addictive behavior or an emotional problem) [13,35]. The presence of acne is associated with social and psychologic problems, and certain acne medications have been linked with an increased risk of suicidal ideation [36].

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    3 . Which of the following is TRUE regarding suicide among older adults?
    A) Untreated depression is a primary cause.
    B) Suicide is rarely preceded by only one factor.
    C) The suicide rate in elderly men is 5.25 times that of same-aged women.
    D) All of the above

    SUICIDE AND SPECIAL POPULATIONS

    The elderly account for roughly 16.37% of suicides but only 13.75% of the population [13]. Suicide rates rise with age for men, especially after 65 years of age, and the suicide rate in elderly men is 5.25 times that of same-aged women; nearly 84% of elderly suicides are among men [13]. The overall rate of elderly suicide is 15.4 per 100,000. However, the rate is 32.24 per 100,000 among elderly white men and 50.67 per 100,000 among white men older than 85 years of age, a rate that is almost 2.5 times the rate for men of all ages. In contrast, the suicide rate of women declines after 60 years of age [13].

    Although undiagnosed and/or untreated depression is the primary cause of suicide in the elderly, suicide completion is rarely preceded by only one factor. Risk factors for suicide in this population include a previous suicide attempt; mental illness; physical illness or uncontrollable pain; fear of a prolonged illness; major changes in social roles, such as retirement; loneliness and social isolation (especially in older men who have recently lost a loved one); and access to means, such as firearms in the home [13].

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    4 . Which of the following contributes to the high rate of suicide attempts among lesbian, gay, bisexual, and transgender youth?
    A) Lower income
    B) Greater family support
    C) Stigma and discrimination
    D) Higher perceived safety at school

    SUICIDE AND SPECIAL POPULATIONS

    LGBT+ youth generally have more risk factors, more severe risk factors, and fewer protective factors, such as family support and safe schools, than heterosexual youth. There are also risks unique to this population related to sexual orientation, such as disclosure to family or friends [13]. The impact of stigma and discrimination against LGBT+ individuals is enormous and is directly tied to risk factors for suicide such as isolation, alienation and rejection from family, and lack of access to culturally competent care [37]. Family connectedness, perceived caring from other adults, and feeling safe at school were reported as significant protective factors in a survey of 6th-, 9th-, and 12th-grade LGBT+ students [51].

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    5 . Which of the following is NOT a protective factor against suicide?
    A) Shame and stigma
    B) Access to effective clinical care
    C) Restricted access to highly lethal means of suicide
    D) Strong connections to family and community support

    RISK AND PROTECTIVE FACTORS FOR SUICIDE

    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

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    6 . Which of the following is an example of a general biopsychosocial risk factor for suicide?
    A) Local clusters of suicide
    B) Media exposure to suicide
    C) History of childhood physical or sexual abuse
    D) Barriers to accessing mental health care or support

    RISK AND PROTECTIVE FACTORS FOR SUICIDE

    In addition to risk factors specific to special populations, there are many general risk factors common among most populations. 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)

    • Family history of suicide

    • Suicidal ideas, plans, or attempts (current or previous)

    • Lethality of suicidal plans or attempts

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    7 . What proportion of persons who die of suicide have diagnosable psychiatric illness at the time of death?
    A) Less than 10%
    B) 25%
    C) 50%
    D) 90%

    RISK AND PROTECTIVE FACTORS FOR SUICIDE

    At least 90% of people who complete suicide have diagnosable psychiatric illness [2,3]. The psychiatric conditions with the greatest association with suicidal behavior are depression, bipolar disorder, substance abuse, schizophrenia, and personality disorders.

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    8 . The psychiatric condition most associated with suicide is
    A) schizophrenia.
    B) panic disorder.
    C) anxiety disorder.
    D) major depression.

    RISK AND PROTECTIVE FACTORS FOR SUICIDE

    Major depression is the psychiatric diagnosis most commonly associated with suicide. The lifetime risk of suicide among patients with untreated and treated depressive disorder is nearly 20% and 141 per 100,000, respectively [13,63,64]. About 30% of all patients with major depression attempt suicide, half of whom ultimately take their own lives. More than 60% of persons who complete suicide are clinically depressed at the time of their deaths, although this climbs to 75% when alcoholics with depression are added. Seven of every 100 men and 1 of every 100 women diagnosed with depression will complete suicide [13]. Among persons 18 years of age and older who experienced depression in the previous year, 56.3% thought it would be better if they were dead during their worst or most recent episode, 40.3% contemplated suicide, 14.5% made a suicide plan, and 10.4% attempted suicide [65].

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    9 . Which of the following is TRUE regarding alcohol/drug use and suicide?
    A) A substantial proportion of suicide victims test positive for alcohol and/or other drugs.
    B) Comorbid substance use and psychiatric disorders substantially increase the risk of suicidal behavior.
    C) Alcohol and drug abuse are second only to mood disorders as conditions most associated with suicide.
    D) All of the above

    RISK AND PROTECTIVE FACTORS FOR SUICIDE

    Alcohol and drug abuse are second only to depression and other mood disorders as conditions most associated with suicide. The suicide risk among alcoholics is 50% to 70% higher than the general population. Alcohol abuse is a factor in roughly 30% of suicides, and about 7% of persons with alcohol dependence die by suicide [2,13,68].

    In 2011, an estimated 228,366 emergency department admissions were made for alcohol- or drug-related suicide attempts. Almost all (94.7%) involved either a prescription drug or an over-the-counter medication [69]. Approximately 64.4% involved multiple drugs, and 29% involved alcohol [69].

    As mentioned, comorbid psychiatric and substance use disorders substantially increase the risk of suicide behavior. Combined data from 2004 and 2005 indicated that 16.4 million adults 18 years of age and older experienced a major depressive episode in the previous year. Of these persons, more than 10% attempted suicide. But when alcohol abuse or illicit drug use occurred with major depression, the proportion of suicide attempts rose to nearly 14% for alcohol abuse and close to 20% for illicit drug use [14,65].

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    10 . Which of the following is considered a risk factor for suicide in military veterans?
    A) Traumatic brain injury
    B) Administrative separation from service/unit
    C) Combat exposure (particularly deployment to a combat theater and/or adverse deployment experiences)
    D) All of the above

    RISK AND PROTECTIVE FACTORS FOR SUICIDE

    Veterans often possess many risk factors for attempting or completing suicide. This includes combat exposure (particularly deployment to a combat theater and/or adverse deployment experiences), combat wounds, post-traumatic stress disorder (PTSD) and other mental health problems, comorbid major depression, traumatic brain injury, poor social support, feelings of not belonging or of being a burden to others or society, acquired ability to inflict lethal self-injury, and access to lethal means [58,81,82,83]. There is conflicting evidence of the role of PTSD in suicide risk, with some studies finding PTSD diagnosis to be protective while others indicated it increased risk. Other possible risk factors include [79]:

    • Disciplinary actions

    • Reduction in rank

    • Career threatening change in fitness for duty

    • Perceived sense of injustice or betrayal (unit/command)

    • Command/leadership stress, isolation from unit

    • Transferring duty station

    • Administrative separation from service/unit

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    11 . Which of the following is a warning sign of imminent suicide?
    A) Decreased alcohol and/or other drug use
    B) Distant history of humiliation, failure, or severe loss
    C) Making a plan (e.g., giving away prized possessions)
    D) Recent inhibition and unwillingness to take necessary risks

    IMMINENT SUICIDE

    Most people who are suicidal exhibit warning signs, whether or not they are in an acute suicide crisis. These warning signs should be taken seriously and include observable signs of serious depression, such as unrelenting low mood, pessimism, hopelessness, desperation, anxiety, psychic pain, and inner tension; withdrawal from friends and/or social activities; sleep problems; and loss of interest in personal appearance, hobbies, work, and/or school [2,13]. Other signs include:

    • Increased alcohol and/or other drug use

    • Recent impulsiveness and taking unnecessary risks

    • Talk about suicide, death, and/or no reason to live

    • Making a plan (e.g., giving away prized possessions, sudden or impulsive purchase of a firearm, or obtaining other means of killing oneself, such as poisons or medications)

    • Unexpected rage, anger, or other drastic behavior change

    • Recent humiliation, failure, or severe loss (especially a relationship)

    • Unwillingness to "connect" with potential helpers.

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    12 . What is the most commonly used lethal means in suicide completions?
    A) Firearms
    B) Prescription drugs
    C) Rope (i.e., suffocation)
    D) Household toxins (e.g., bleach)

    SUICIDE ATTEMPTS

    In the United States, use of a firearm is the cause of death in 52.3% of suicides and is the number one means among adults 35 years of age and older. Gun use is also the most common suicide method among youth, accounting for 44.4% of all suicide deaths. Firearms are also the most common means (53%) among the elderly [1].

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    13 . Intermediate acute risk patients include those patients with
    A) recent suicidal ideation who have no specific plans or intent to engage in lethal self-directed violence and have no history of active suicidal behavior.
    B) an appropriately managed mental disorder who do not report suicidal thoughts.
    C) current suicidal ideation but with no intent or preparatory behavior.
    D) warning signs, serious thoughts of suicide, a plan and/or intent to engage in lethal self-directed violence, a recent suicide attempt, and/or those with prominent agitation, impulsivity, psychosis.

    SCREENING AND ASSESSMENT OF SUICIDE RISK

    DETERMINE LEVEL OF RISK FOR SUICIDE AND APPROPRIATE ACTION

    Risk of Suicide AttemptIndicators of Suicide RiskContributing FactorsaInitial Action Based on Level of Risk
    High acute risk
    Persistent suicidal ideation or thoughts
    Strong intention to act or plan
    Not able to control impulse
    Recent suicide attempt or preparatory behaviorb
    Acute state of mental disorder or acute psychiatric symptoms
    Acute precipitating event(s)
    Inadequate protective factors
    Maintain direct observational control of the patient
    Limit access to lethal means
    Immediate transfer with escort to urgent/emergency care setting for hospitalization
    Intermediate acute risk
    Current suicidal ideation or thoughts
    No intention to act
    Able to control the impulse
    No recent attempt or preparatory behavior or rehearsal of act
    Existence of warning signs or risk factorsb and limited protective factors
    Refer to behavioral health provider for complete evaluation and interventions
    Contact behavioral health provider to determine acuity of referral
    Limit access to lethal means
    Low acute risk
    Recent suicidal ideation or thoughts
    No intention to act or plan
    Able to control the impulse
    No planning or rehearsing a suicide act
    No previous attempt
    Existence of protective factors and limited risk factors
    Consider consultation with behavioral health to determine need for referral and treatment
    Treat presenting problems
    Address safety issues
    Document care and rationale for action
    aModifiers that increase the level of risk for suicide of any defined level include acute state of substance use, access to means (e.g., firearms, medications), and existence of multiple risk factors or warning signs or lack of protective factors.
    bEvidence of suicidal behavior warning signs in the context of denial of ideation should call for concern (e.g., contemplation of plan with denial of thoughts or ideation).
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    14 . Which of the following is an appropriate initial action for a person who is at low acute risk for suicide?
    A) Treat presenting problems
    B) Refer to behavioral health provider for complete evaluation and interventions
    C) Immediate transfer with escort to urgent/emergency care setting for hospitalization
    D) Maintain direct observational control of the patient

    SCREENING AND ASSESSMENT OF SUICIDE RISK

    DETERMINE LEVEL OF RISK FOR SUICIDE AND APPROPRIATE ACTION

    Risk of Suicide AttemptIndicators of Suicide RiskContributing FactorsaInitial Action Based on Level of Risk
    High acute risk
    Persistent suicidal ideation or thoughts
    Strong intention to act or plan
    Not able to control impulse
    Recent suicide attempt or preparatory behaviorb
    Acute state of mental disorder or acute psychiatric symptoms
    Acute precipitating event(s)
    Inadequate protective factors
    Maintain direct observational control of the patient
    Limit access to lethal means
    Immediate transfer with escort to urgent/emergency care setting for hospitalization
    Intermediate acute risk
    Current suicidal ideation or thoughts
    No intention to act
    Able to control the impulse
    No recent attempt or preparatory behavior or rehearsal of act
    Existence of warning signs or risk factorsb and limited protective factors
    Refer to behavioral health provider for complete evaluation and interventions
    Contact behavioral health provider to determine acuity of referral
    Limit access to lethal means
    Low acute risk
    Recent suicidal ideation or thoughts
    No intention to act or plan
    Able to control the impulse
    No planning or rehearsing a suicide act
    No previous attempt
    Existence of protective factors and limited risk factors
    Consider consultation with behavioral health to determine need for referral and treatment
    Treat presenting problems
    Address safety issues
    Document care and rationale for action
    aModifiers that increase the level of risk for suicide of any defined level include acute state of substance use, access to means (e.g., firearms, medications), and existence of multiple risk factors or warning signs or lack of protective factors.
    bEvidence of suicidal behavior warning signs in the context of denial of ideation should call for concern (e.g., contemplation of plan with denial of thoughts or ideation).
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    15 . Which of the following is NOT a characteristic shared by effective suicide prevention programs?
    A) Definition of the desired outcomes
    B) Clear identification of the intended population
    C) Use of interventions known to effect a particular outcome
    D) Acting independently to eliminate the need for coordination

    SUICIDE PREVENTION

    Understanding the interactive relationship between risk and protective factors in suicidal behavior and how this interaction can be modified forms the basis of suicide prevention [5,106]. The characteristics shared by effective suicide prevention programs include clear identification of the intended population, definition of desired outcomes, use of interventions known to effect a particular outcome, and use of community coordination and organization to achieve an objective. Prevention efforts are based on a clear plan with goals, objectives, and implementation steps [5].

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