September is suicide prevention month. I thought this would be a good time to remind our readers of the risk factors for suicide and an approach to assessment of the suicidal patient.
Suicide is one of the leading causes of death in the US. The most recent statistics indicate there were over 48,000 deaths due to suicide in 2024. It is the 2nd most common cause of death in the age group 15 to 34. Rates of suicide vary by state with Alaska having the highest rate of 29.8 deaths by suicide per 100,000 population, whereas DC has the lowest at 5.7/100,000.
The most common method is by firearm in over 50% of cases. Asphyxia (hanging) comes second, and drug overdose represents only about 9% of cases. Males outnumber females 4 to 1 in completed suicides. The white population is 2x more likely to commit suicide than the black or Hispanic population.
Risk factors can be divided into 3 categories: biological, social, and psychological.
We know that white males aged 45-54 and 75-84 with a recent diagnosis or chronic disease are at the highest biological risk.
Social risk factors include establishing a will or making funeral arrangements, having access to means of suicide such as firearms, having a recent suicide exposure, a recent stressful life event such as loss of a loved one, and those with limited social support.
Psychological risk factors before suicide attempts include personal or family history of suicide attempts, hopelessness, insomnia, irritability, psychiatric illness, and substance abuse.
These recognized suicide risk factors have been identified in population research, but it must be stressed that they are risk factors and not prediction factors for an individual patient. In fact, many patients with positive risk factors do not commit suicide, and over half of patients with no risk factors do commit suicide.
So, when assessing an individual’s risk for suicide, we can’t just rely on known suicidal risk factors. Every individual is unique; their situation, state of mind, plan, and access to means of suicide must all be taken into account in assessment in addition to known risk factors.
In a patient you are concerned about, the best approach is to ask about suicidal thoughts. Ask if they have had thoughts of death and self-harm. Don’t be afraid to bring this up. You will not cause the patient to develop suicidal ideation or trigger a suicidal attempt by asking this. Research has shown that asking this directly leads to better outcomes.
Begin by asking the patient how things are going in their life. Then ask about thoughts of death and self-harm. If they indicate they are thinking about it, ask them to talk through how they are planning to do it and what they expect if they are successful. This can differentiate between the actively suicidal and those that just thinking about it. However, both are a serious concern and need assessment by a mental health professional.
I have often asked, “What is stopping you from going through with it?” This can be helpful because it identifies protective factors such as a strong religious belief or a responsibility for family. It helps identify ambivalence and highlights reasons for not committing suicide.
It is important to listen without judgement. The person must be able to talk freely without any effort on your part to minimize or “fix” their feelings. You must build trust by showing compassion and acceptance of their feelings. Ask them about support in their life, such as family or friends, and encourage them to go with you to the hospital to get professional help.
References:
Large MM, Ryan CJ, Carter G, Kapur N. Can we usefully stratify patients according to suicide risk? BMJ. 2017 Oct 17;359:j4627. doi: 10.1136/bmj.j4627. PMID: 29042363. Access at file:///C:/Users/mgewe/Downloads/Publisher%20version%20(open%20access)_ATTACHMENT02.pdf .
Mathias CW, Michael Furr R, Sheftall AH, Hill-Kapturczak N, Crum P, Dougherty DM. What’s the harm in asking about suicidal ideation? Suicide Life Threat Behav. 2012 Jun;42(3):341-51. Access at https://pmc.ncbi.nlm.nih.gov/articles/PMC3597074/.
Norris DR, Clark MS. The Suicidal Patient: Evaluation and Management. American Family Physician. 2021;103(7):417–421. Access at https://www.aafp.org/afp/2021/0401/p417#afp20210401p417-b14.
