The Suicidal Patient: Evaluation and Management

 

Am Fam Physician. 2021 Apr 1;103(7):417-421.

  Patient information: Handouts on this topic are available at https://familydoctor.org/depression-coping-with-suicidal-thoughts and https://www.aafp.org/afp/2012/0315/p610.html.

Related editorial: Preventing Physician Suicide

Author disclosure: No relevant financial affiliations.

Suicide rates in the United States increased from 20% to 30% between 2005 and 2015, and family physicians need evidence-based resources to address this growing clinical concern. Asking high-risk patients (e.g., patients with previous suicide attempts, substance misuse, low social support) about suicidal intent leads to better outcomes and does not increase the risk of suicide. There is insufficient evidence to support routine screening. Important elements of the patient history include the intent, plan, and means; availability of social support; previous attempts; and the presence of comorbid psychiatric illness or substance misuse. After intent has been established, inpatient and outpatient management should include ensuring patient safety and medical stabilization, activating support networks, and initiating therapy for psychiatric diseases. Care plans for patients with chronic suicidal ideation include these same steps and referral for specialty care. In the event of a completed suicide, physicians should provide support for family members who may be experiencing grief complicated by guilt, while also activating support networks and risk management systems.

National rates of suicide are increasing, and how people are attempting suicide is becoming more lethal. There have been efforts to systemically reduce suicide rates, such as the Zero Suicide model, which focuses on screening and practice guidelines.1 However, family physicians report feeling unprepared to treat patients who endorse symptoms of suicidality.2 This article presents current data and recommendations to help physicians address this challenging clinical concern.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Clinicians should consider screening patients with possible suicidal ideation for depression, anxiety, and alcohol use to help determine symptom severity.7,10,11

B

Consistent results from population studies and conflicting trials

Direct inquiry about suicidal ideation in patients with risk factors is associated with more effective treatment and management.18,20

B

Expert opinion, consensus guideline, one randomized trial

For patients who have expressed suicidal ideation, crisis planning should be used instead of suicide prevention contracts.17,18,20

B

Expert opinion, consensus guideline, one randomized trial

Treatment of suicidal ideation should include medications and psychological interventions.18

C

Consensus guidelines in the absence of randomized trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Clinicians should consider screening patients with possible suicidal ideation for depression, anxiety, and alcohol use to help determine symptom severity.7,10,11

B

Consistent results from population studies and conflicting trials

Direct inquiry about suicidal ideation in patients with risk factors is associated with more effective treatment and management.18,20

B

Expert opinion, consensus guideline, one randomized trial

For patients who have expressed suicidal ideation, crisis planning should be used instead of suicide prevention contracts.17,18,20

B

Expert opinion, consensus guideline, one randomized trial

Treatment of suicidal ideation should include medications and psychological interventions.18

C

Consensus guidelines in the absence of randomized trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Epidemiology and Risk Factors

In 2017, suicide accounted for more than 47,000 deaths in the United States.3 Suicide is the second leading cause of death in people 10 to 34 years and the 10th leading cause of mortality among adults overall.4 Between 2005 and 2015, suicide rates increased from 20% to 30% in the United States.5 Among completed suicides, firearms are the most common means, accounting for approximately 50%, followed by hanging or suffocation (28%), and poisoning including medication overdose (14%).4

Women are twice as likely as men to attempt suicide6; however, men are nearly four times more likely to die by suicide.3 Men are more likely to use violent means, including firearms and hanging, whereas women use more passive means such as poisoning.4

People 45 to 54

The Authors

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DAVID R. NORRIS, MD, MA, FAAFP, is the assistant dean for academic affairs and a professor of family medicine at The University of Mississippi Medical Center, Jackson....

MOLLY S. CLARK, PhD, is director of the Health Psychology Fellowship and an associate professor at The University of Mississippi Medical Center.

Address correspondence to David R. Norris, MD, MA, FAAFP, The University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216 (email: drnorris@umc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

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