Study Points

Suicide Assessment and Prevention

Course #96441 - $24 • 6 Hours/Credits

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. In 2017, how many suicide deaths were reported in the United States?

    INTRODUCTION

    In 2017, there were 47,173 reported suicide deaths in the United States, making it the 10th leading overall cause of mortality [1]. Every day, approximately 129 Americans take their own life, and one person dies by suicide every 11.2 minutes. An estimated 90% of persons who complete suicide have a diagnosable psychiatric disorder at the time of death, although only 46% have a documented diagnosis [2,3].

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  2. The only country in which the female suicide rate exceeds the male rate is

    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 (36,782) than among women (10,391). Overall, suicide accounts for 1.7% of all deaths in the United States [1].

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  3. Which of the following relationship statuses is NOT a high-risk demographic for suicide among women?

    SUICIDE AND SPECIAL POPULATIONS

    A woman takes her own life every 49.7 minutes in the United States [1]. Suicide is more common among women who are single, recently separated, divorced, or widowed, and the suicide rates for women peak between the ages of 45 to 54 years, and again after 75 years of age. Precipitating life events for women who attempt suicide often involve interpersonal losses or crises in significant social or family relationships. As noted, more women attempt suicide than men, and there is a 3.5:1 ratio of women versus men with a history of attempted suicide. The higher rates of attempted suicide among women are likely due to the higher rates of mood disorders such as major depression, persistent depressive disorder (dysthymia), and seasonal affective disorder. Factors that may contribute to the lower rates of completed suicide in women relative to men include stronger social supports, feeling that their relationships are a deterrent to suicide, differences in preferred suicide method, and greater willingness to seek psychiatric and medical intervention [2,13].

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  4. Most adolescent suicides occur at

    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) [13,33]. 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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  5. Which of the following is TRUE regarding suicide among older adults?

    SUICIDE AND SPECIAL POPULATIONS

    The elderly account for roughly 18.8% of suicides but only 16% 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 4.96 times that of same-aged women; more than 83% of elderly suicides are among men [13,35]. The overall rate of elderly suicide is 18 per 100,000. However, the rate is 31.2 per 100,000 among elderly white men and 51.8 per 100,000 among white men older than 85 years of age, a rate that is almost 2 times the rate for men of all ages. In contrast, the suicide rate of women declines after 60 years of age [13,35].

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  6. Which of the following contributes to the high rate of suicide attempts among lesbian, gay, bisexual, and transgender youth?

    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 [43]. 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 [37,38]. It has also been noted that LGBT+ adults have a two-fold excess risk of suicide than their heterosexual counterparts [37].

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  7. Which of the following is NOT a protective factor against suicide?

    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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  8. Which of the following is an example of a general biopsychosocial risk factor for suicide?

    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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  9. What proportion of persons who die of suicide have diagnosable psychiatric illness at the time of death?

    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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  10. The psychiatric condition most associated with suicide is

    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]. 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 patients with comorbid depression and alcohol use disorder 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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  11. Which of the following is TRUE regarding alcohol/drug use and suicide?

    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 patients with alcohol use disorder 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].

    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 [65]. A 2017 study conducted among more than 10,000 individuals in a prison population showed that those with a documented substance abuse disorder or other psychiatric disorder had a higher rate of attempted suicide (2.0 and 9.2 greater odds, respectively) than those without a diagnosis [41].

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  12. Which of the following sociodemographic factors is NOT associated with increased suicide risk?

    RISK AND PROTECTIVE FACTORS FOR SUICIDE

    Divorced, widowed, and single people have a higher suicide risk. Marriage appears to be protective for men, but not so for women. Marital separation also increases the risk of suicide [59,60].

    Certain occupational groups, such as veterinary surgeons, pharmacists, dentists, farmers, and medical practitioners, have higher rates of suicide. Although obvious explanations are lacking, access to lethal means, work pressure, social isolation, and financial difficulties may account for the heightened risk [59,60].

    Unemployment and suicide are also correlated, although the nature of the association is complex. Poverty, social deprivation, domestic difficulties, and hopelessness likely mediate the effect of unemployment, but persons with psychiatric illness and personality disorders are also more likely to be unemployed. Recent job loss is a greater risk factor than long-term unemployment.

    Approximately 20% of people who kill themselves had made a previous attempt, making previous serious suicide attempts a very high risk factor for future attempts [2].

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  13. Which of the following is considered a risk factor for suicide in military veterans?

    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 [52,58,81,82,83]. 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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  14. Which of the following is a warning sign of imminent suicide?

    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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  15. Superficial-to-moderate intentional self-harm is characterized by

    IMMINENT SUICIDE

    Intentional self-harm is behavior related to, but distinct from, suicide behavior and includes suicide attempts and nonsuicidal self-injurious behaviors, such as burning, cutting, and hair pulling, that does not have fatal intent [85]. Self-injurious behavior falls into three categories [85]:

    • Major self-injury: Infrequent, usually associated with psychosis or intoxication

    • Stereotypic self-injury: Repetitive and reflects a biologic drive of self-harm

    • Superficial-to-moderate self-injury: The most common form and is used by self-mutilators to relieve tension, release anger, regain self-control, escape from misery, or terminate a state of depersonalization

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  16. What is the most commonly used lethal means in suicide completions?

    SUICIDE ATTEMPTS

    In the United States in 2017, use of a firearm was the cause of death in 50.6% of suicides and is the number one means among all individuals 15 years of age and older. Gun use accounts for 58.8% of all completed suicides in individuals 15 to 24 years of age, reaching a low of 42.4% in those 35 to 44 years of age, and increasing to 52.8% in those 55 to 64 years of age. Firearm use for suicide completion is extremely high among the elderly, with individuals 75 to 84 having the highest rate at 77%, followed by 74.4% among those 85 years of age and older. Gun use is also the most common suicide method among youth, accounting for 47.2% of all suicide deaths [1].

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  17. All of the following are recommended in the assessment of suicide risk, EXCEPT:

    SCREENING AND ASSESSMENT OF SUICIDE RISK

    Healthcare providers may encounter a patient they suspect is suicidal. This suspicion may be prompted by the presence of one or more of the risk factors for suicide described previously, patient history, a statement expressed by the patient, or by their intuition. This scenario may present a dilemma of how to proceed. Although some healthcare professionals are uncomfortable with suicidal patients, it is essential not to ignore or deny the suspicion of suicide risk. The first and most immediate step is to allocate adequate time to the patient, even though many others may be scheduled. Showing a willingness to help begins the process of establishing a positive rapport with the patient. Closed-ended and direct questions at the beginning of the interview are not very helpful; instead, use open-ended questions such as, "You look very upset; tell me more about it." Listening with empathy is in itself a major step in reducing the level of suicidal despair and overall distress [59,60]. It is helpful to lead into the topic gradually with a sequence of useful questions, such as [59,60]:

    • Do you feel unhappy and helpless?

    • Do you feel desperate?

    • Do you feel unable to face each day?

    • Do you feel life is a burden?

    • Do you feel life is not worth living?

    • Have you had thoughts of ending your own life?

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  18. Intermediate acute risk patients include those patients with

    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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  19. Which of the following is an appropriate initial action for a person who is at low acute risk for suicide?

    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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  20. Which of the following is NOT a characteristic shared by effective suicide prevention programs?

    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 [5,45].

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.