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

Related editorial: Preventing Physician Suicide

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.

This clinical content conforms to AAFP criteria for CME.

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.

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 1.3,11,12,1416

Biologic
Age (45 to 54 years and 75 to 84 years)
Cisgender male
Race (White)
Recent illness diagnosis or chronic disease
Environmental/social
Access to means
Changes in future plans (e.g., changing or establishing a will; making funeral arrangements)
Recent suicide exposure
Stressful life event (e.g., death of loved one, unemployment, end of a relationship, legal issues)
Unmarried or limited social support
Psychological
Feelings of social isolation (including members of the lesbian, gay, bisexual, transgender, queer+ community)
History of suicide attempts (personal or family)
Hopelessness
Insomnia
Irritability
Psychiatric history (personal or family), such as anxiety, mood disorders, schizophrenia, borderline personality disorder
Substance (including ethanol) misuse disorder

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

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