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.

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 years and 75 to 84 years have the highest suicide rates; however, increases in other age groups have almost eliminated the age differences. Suicidal thoughts, plans, and attempts are highest among people 18 to 25 years, compared with older age groups.⁷ White people are twice as likely to die by suicide as Black or Hispanic people.³ Compared with their heterosexual peers, gay men and women are twice as likely to die by suicide, and more than 40% of people who identify as transgender have attempted suicide in their lives.^8,9 People living in rural areas are more likely to commit suicide and to do so by firearm. Non-Hispanic American Indian/Alaska Native people living in rural areas are also at increased risk of suicide.¹⁰

One of the key risk factors for suicide attempts and completion is a comorbid psychiatric illness, particularly in patients who have previously attempted suicide. These conditions include anxiety, mood, psychotic, and substance misuse disorders.^7,10,11 Although people with depressive disorders have the highest risk, substance misuse, without comorbid psychiatric concerns, is also a significant risk factor because it may be used to mask other illnesses or it provides the decreased inhibition necessary to attempt suicide. In patients with psychotic disorders, those who have schizophrenia with hallucinations instructing them to harm themselves (i.e., command hallucinations) are at the highest risk, and those with frequent and severe exacerbations, fear of further psychiatric decline, and significant functional impairment are also at highest risk in this group.¹² Medical illnesses, such as terminal health conditions, chronic obstructive pulmonary disease, chronic pain, and traumatic brain injuries also increase the risk of suicide.¹³ A summary of risk factors is available in Table 1.^{3,11,12,14–16}

Evaluation

The U.S. Preventive Services Task Force concluded that there is insufficient evidence to demonstrate that routine screening for suicide risk in adolescents, adults, and older adults reduces attempts or mortality from suicide.¹⁷ Tools such as the nine-item Patient Health Questionnaire (PHQ-9; https://www.mdcalc.com/phq-9-patient-health-questionnaire-9) are available to screen for suicidal ideation. There is support for using item 9 (i.e., in the past two weeks have you had “Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?”) of the PHQ-9 as a component of screening during a clinical interview.¹⁸