Each year, more than 30,000 Americans take their own lives. An additional 500,000 Americans visit emergency rooms for self-inflicted injuries. Suicide is the third leading cause of death among children, teens and young adults ages 10 to 24. In the United States, about 4,000 young people die by suicide each year. Of the total number of suicides among ages 15 to 24 years, approximately 80% were male and 20% were female. And, every year, approximately 125,000 children and young people are brought to emergency rooms to receive treatment for injuries sustained while attempting suicide.(1) The vast majority of these young people are between 15 and 24 years of age.(2) In 2002, over 130,000 individuals were hospitalized following suicide attempts.

Males are four times more likely to die from suicide than females, while females are three times more likely than males to attempt suicide.(2) Suicide rates are highest among Whites and second highest among Native American and Native Alaskan males.(1) Annually, approximately 60% of all suicidal deaths in the USA involve the use of a firearm.

Older people are also at increased risk of suicide.(3) This is especially true of older men -- 85 percent of people dying by suicide over the age of 65 are men.(2) Over 80% of elderly suicidal deaths involve the use of firearms. Older adults who are suicidal are also more likely to be suffering from physical illnesses and be divorced or widowed.(4)

Risk Factors

Suicidal behaviors are complex behavioral expressions emanating from multiple etiologies (psychological, biological, genetic, sociological, economic, etc.).(5) Risk factors are anything that increases the likelihood that an individual will harm themselves, although risk factors are not necessarily causes. Research has identified the following risk factors for suicide:(4),(6))

Ninety percent of suicides that take place in the United States are associated with mental illness, including disorders involving the abuse of alcohol and other drugs.(7) Fifty percent of those who die by suicide were afflicted with major depression and the suicide rate of people with major depression is eight times that of the general population.(8)

The relationship between suicide and family history is complicated and not fully understood. People with a parent, sibling or child who has died by suicide have a six-fold increased risk of doing the same. However, it is important to remember that most people who have had a close relative die by suicide do not attempt to kill themselves. Having a supportive family can protect people from suicide and self-harm.(9) Some suicidal behavior may have a genetic component (possibly involving a predisposition to emotional illness combined with impulsiveness).(7)

Protective Factors

Protective factors are believed to enhance resilience and serve to counterbalance risk factors. Protective factors can include:(6)

The Role of Primary Care Physicians in Preventing Suicide

Since physical illness itself is a risk factor for suicide,(10) primary care physicians and other health care providers are highly likely to see patients who are depressed and may be at risk of suicide. Most people who complete suicide signal their intention to do so before ending their lives and they often display these distress signals to their doctors. A substantial number of elderly people who die by suicide contact their primary care physicians within a month before their death.(3)

The majority of patients who have risk factors for suicide will not die by suicide. However, the presence of multiple risk factors should alert the physician to the possibility that a patient may be at increased risk if there is the emergence of life stressors or sudden changes in their biopsychosocial environment that challenge the patient's ability to adapt and cope. Successful intervention to prevent suicide will depend on your ability to recognize the warning signs of increased suicidal risk, and to make sure that your patient receives immediate and appropriate care for what is a life-threatening condition.

Warning Signs

People who are in danger of harming themselves may try to reach out to their primary care physicians -- sometimes directly, sometimes indirectly (a "cry for help"). Rarely will patients immediately volunteer the information that they are thinking of harming themselves. Instead, they often describe their concerns in terms of physical symptoms.

As a physician, you should be alert for warning signs that a patient may be at increased risk of suicide, whether or not they carry identifiable risk factors. Warning signs include:

These signs are especially critical if the patient has a history or current diagnosis of a psychiatric disorder such as depression, anxiety or panic disorder, alcohol or drug abuse, bipolar disorder or schizophrenia.

People of different ages are at different levels of risk and display different types of warning signs. In addition, cultural influences, including the specific ethnic and religious culture(s) that are important to the individual, may shape how they convey signs and symptoms of emotional distress. Research indicates that many older adults who visited a primary care physician within a month of dying by suicide had an undiagnosed mental illness associated with suicide such as depression,(3) or had a common medical condition associated with an increased risk of suicide such as diabetes, cancer (especially head and neck), renal failure, peptic ulcer, rheumatoid arthritis or Cushing's disease.(10) Physicians should pay careful attention to elderly patients who are physically ill and who exhibit any of the following warning signs of suicide:(24)

Adolescents are also at an increased risk of dying by suicide, though their warning signs are different. Be alert for the following:

Although rare, children are also at risk for suicide. Although the rate of suicide in 10-14 year olds has been slowly increasing over the last five years, it has been difficult to enumerate the common risk factors or warning signs most often associated with suicidal behaviors in this age group.(4),(6)

Responding to the Warning Signs

There are no hard and fast guidelines for determining a patient's risk of suicide. However, if you suspect that your patient may be at risk, you can ask the sometimes difficult questions that will provide you with more evidence about his or her state of mind and intentions, for example:

You should act immediately if you have any reason to believe that the patient is in imminent danger or poses a grave danger to him- or herself. Immediate action should also be taken when warning signs are combined with any of the following risk factors:

You can help protect a patient by doing the following:

If you have any suspicions that a patient is seriously considering harming him- or herself, let your patient know that you care, that he or she is not alone and that you are there to help. You may have to work with the patient's family to ensure that he or she will be adequately supported until a mental health professional can provide an assessment. In some cases, you may have to accompany your patient to the emergency room at an area hospital or crisis center.

If the person is uncooperative, combative or otherwise unwilling to seek help, and if you sense that the person is in acute danger, call 911 or (800) 273-TALK (8255). Tell the dispatcher that you are concerned that the person with you "is a danger to [him- or herself]" or "cannot take care of [him- or herself]." These key phrases will alert the dispatcher to locate immediate care for this person with the help of police. Do not hesitate to make such a call if you suspect that someone may be a danger to him- or herself. It could save that person's life.

Conceptual Foundations for Treating Suicidal Patients

One of the most exciting advances in understanding the genetic and biological bases for suicidal behavior is John Mann's proposed stress-diathesis model of suicide, which is based on research findings in neurobiology.(11),(12) Basic neurobiological research about the role of neurotransmitters (e.g., serotonin, dopamine, norepinephrine) in the modulation of brain function has led to the theoretical proposition that a vulnerability to suicidality may exist independently of those stressors (or risk factors) that have been correlated with suicidal behavior (especially psychiatric disorders such as mood disorders, schizophrenia, anxiety disorder, substance abuse disorders and certain personality disorders).

Mann and colleagues propose that there is a diathesis, or predisposition to suicidal behavior, that has distinct biological underpinnings. They contend that there are biological correlates of this diathesis for suicidal behavior as well as biological correlates of the stressors for suicidal behavior, such as major psychiatric disorders.(11) Each of these two domains has different biological correlates leading to different therapeutic approaches.(10)

Empirical evidence is mounting that the most common diagnostic condition related to suicide, major depression, is clearly associated with impaired serotonergic function involving different brain regions (predominantly the ventral prefrontal cortex) but is independent of the serotonergic abnormality associated with the vulnerability or diathesis for suicidal behavior.(13) The familial transmission of the stressors (i.e., psychiatric illnesses) is independent of the familial transmission of the diathesis for suicidal behavior. Hence, these authors postulate that there are familial, and almost certainly genetic, factors related to the diathesis for suicidal behavior. The consequence of such genetic factors most likely is a biological abnormality or phenotype.

Antidepressants and the Risk of Suicidal Behaviors

Medications and medication management can play a role in the therapy of suicidal adolescents and young adults. Medications may be helpful in cases where the diagnostic condition and related symptoms can benefit from the judicious use of certain medications.(10) This may be particularly true in a case where a needed level of symptom reduction allows for greater accessibility to and success with cognitive, behavioral or verbal modes of clinical psychotherapeutic intervention.

Antidepressants are the class of medications scientifically shown to be effective in reducing the symptoms of depression. They have also been shown to be effective in the treatment of obsessive-compulsive disorder, panic disorder, eating disorder, tobacco dependence, as well as other disorders. The use of medications (especially antidepressants) should always be considered when developing a comprehensive treatment plan for patients with a major depressive disorder, or when a patient expresses suicidal ideation, intent or plans.

There are reasons to believe that selective serotonin reuptake inhibitors (SSRIs) might reduce suicidality because of their potential to reduce irritability, affective response to stress, hypersensitivity, depression and anxiety.(14) SSRIs may effectively reduce suicidal ideation.(15) SSRIs remain the preferred psychopharmacological treatment for young adult depression, with caution that suicidal patients on SSRIs must be watched for any increase in agitation or suicidality, especially in the early phase of treatment.(16)

Recently, the Food and Drug Administration (FDA) has determined that there is some evidence for an association between the administration of SSRIs and the emergence of suicidal behaviors, particularly in children and adolescents. It remains speculative if SSRIs might specifically increase akathisia (the pattern of intense inner restlessness often associated with neuroleptic and antidepressant drugs) in children and adolescents. If they do, even in a very small percentage of patients, it would speak to the use of concomitant medications to address this side effect -- at least during the initial phases of antidepressant medication treatment.

Although akathisia is a relatively rare side effect, it is incumbent that during the first few months of treatment with any antidepressant medication the mental health professional carefully monitor for this side effect as well as for the signs and symptoms of depression. Careful monitoring might include frequent contact (in person or by telephone), education of family and support networks in the monitoring of the emergence of suicidal ideation and behaviors and the provision of emergency contact information.

Dosage levels must be considered carefully and hoarding of pills by the patient prevented. In a similar sense, access to medications by a suicidal young adult must be severely limited. While medications may be essential in the stabilization and treatment of the suicidal young adult, all administration must be carefully monitored by a third party who can report any unexpected change of mood, increase in agitation or emergency state, or unwanted side effects, and who can regulate dosage.(17) Because the management of suicidal patients is complex, it is highly recommended that a psychiatrist be consulted or that the patient be referred to a psychiatrist for more specialized assessment and intervention.

Voluntary Admission and Involuntary Commitment

If a determination is made that a patient needs an inpatient assessment or treatment, it is always preferable to have the patient be an active participant in the decision to be hospitalized. It is always preferable for the patient to agree voluntarily to be hospitalized and to "sign in" on their own -- taking full responsibility for their decision and acknowledging the purpose of the hospitalization. When it is deemed that a patient is a danger to himself/herself or to others, and therefore needs to be hospitalized, the patient can voluntarily consent to the admission.

When the patient is incapable (or refuses) to "sign in" voluntarily, it is incumbent upon the clinician to initiate an involuntary commitment process, ideally in collaboration with the patient's family or significant other, whereby the patient is hospitalized against their will. All states have policies and procedures to initiate and complete the involuntary commitment process. When working with mentally ill patients, and especially those at increased risk for suicide, it is the responsibility of the clinician to be familiar with voluntary and involuntary admission procedures in their community.

The Prevention of Suicide

Few schools and communities have comprehensive suicide prevention plans that include screening, referral and crisis intervention programs. As noted by Hendin et al.,(18) given the large number of risk and protective factors that are related to suicide, many different approaches have been taken to address points along the hypothesized pathway that leads from health to completed suicide. Although many different programs have been developed, mostly aimed at high school students, very few have been systematically evaluated for their short- and long-term efficacy and effectiveness. Hendin et al. point out that there are multiple difficulties in attempting to determine the impact of programs implemented among relatively small samples of students on the statistically rare events of suicide attempts or suicide completions. Hence, programs have tended to rely on proximal outcomes such as increased knowledge, improved attitudes and increased referrals to treatment.

Gould and Kramer(19) argue that suicide prevention strategies for youth have two general goals: case finding, with accompanying referral and treatment, and risk factor reduction. They list the following case finding strategies: school-based suicide awareness curricula, screening, gatekeeper training, and crisis centers and hotlines. Under risk factor reduction strategies they list: restrictions of lethal means, media education, postvention (intervention after a suicide), crisis interventions and skills training (e.g., symptom management and competency enhancement for youth).

Screening programs employ a screening instrument to identify high-risk youth for further assessment and treatment. Popular programs such as SOS and TeenScreen do offer research findings which indicate that they effectively identify teens at risk,(20) and do not result in the iatrogenic development of suicidal behaviors.(21) Screening for mood changes, depression, suicide ideation and substance abuse may be an important tool to identify outpatients at risk for suicide.

The American Academy of Child and Adolescent Psychiatry(17) identified the following public health approaches to suicide prevention in children and adolescents: (a) crisis hotlines; (b) method restriction; (c) indirect case-finding by educating potential gatekeepers, teacher, parents, clergy and peers to identify the "warning signs" of an impending suicide; (d) direct case-finding among high school or college students or among the patients of primary practitioners by screening for conditions that place teenagers at risk for suicide; (e) media counseling to minimize imitative suicide; and (f) training professionals to improve recognition and treatment of mood disorders.

Conclusions

To reduce the rising toll of premature deaths due to suicide, and to protect family and friends from the psychological burden and pain associated with surviving the death of a loved one, the greatest needs seem to be increased awareness, recognition and response to youth and the elderly in need and in times of crisis. This heightened sensitivity to the potential for self-injurious behaviors befalls parents, educators, school personnel, health care professionals, mental health professionals, clergy, first responders (firefighters, police, emergency technicians), and even youth and the elderly themselves.

Public education campaigns as well as professional training is needed to educate about the signs and symptoms of suicidal behavior, and how and when to intervene. For the public this means learning how to ask about suicidal thoughts and behaviors in a non-judgmental and supportive manner, how to convince a person to seek help, and how to ensure that the individual properly receives help.(22) For the physician it means knowing when to ask, how to ask, how to listen for the tell-tale answers, and how to protect the patient from self-harm, which often includes how to work with friends and family members to provide safety, security, support and stability. Resources to provide effective interventions must be available at the community level and they must be affordable, accessible and age-appropriate. The locus of intervention must be targeted first to the family, community (church and school) and physician's office.

The stigma of mental illness and the stigma associated with self-injurious or self-destructive behaviors remain obstacles to seeking care and remaining in care. Slowly our society is beginning to accept the fact that mental disorders are common and are treatable. We, as physicians, have an obligation to our patients to ensure that we don't perpetuate or model the stigmas associated with mental illnesses, and that we work for parity and accessibility of mental health services in our communities.

As a society, we may well not be able to eliminate all the risk factors that increase the potential for suicidal behavior. However, as clinicians and public health workers, we all can surely agree that the enhancement of resilience or protective factors are at least as essential as risk reduction in preventing suicide. Such a dual-pronged strategy -- at both the clinical and public health level -- sustained over time, will most likely achieve the outcomes that we all seek to effectively reduce the incidence and prevalence of suicide and suicidal behaviors in our communities. After all, suicidal behaviors are treatable and suicide is preventable.

Resources

Resources for Primary Care Physicians

Online Resources

American College of Emergency Physicians. (1997, reaffirmed 2001). Civil commitment: ACEP policy statement. Retrieved March 23, 2005, from http://www.acep.org/webportal/PracticeResources/ PolicyStatementsByCategory/MentalHealth/default.htm

Bronheim, H. E., Fulop, G., Kunkel, E. J., Muskin, P. R., Schindler B. A., Yates W. R., et al. (1998). The Academy of Psychosomatic Medicine practice guidelines for psychiatric consultation in the general medical setting. Psychosomatics, 39(4), S8-S30. Retrieved March 23, 2005, from http://www.apm.org/prac-gui/psy39- s8.shtml

Frierson R. L., Melikian M., & Wadman, P. C. (2002). Principles of suicide risk assessment. How to interview depressed patients and tailor treatment. Postgraduate Medicine, 112(3), 65-66, 69-71. Retrieved March 23, 2005, from http://www.postgradmed.com/issues/2002/09_02/frierson4.htm

Gliatto, M. F., & Rai, A. K. (1999). Evaluation and treatment of patients with suicidal ideation. The American Family Physician, 59(6), 1500-1506. Retrieved March 23, 2005, from http://www.aafp.org/afp/990315ap/1500.html

Office of Quality and Performance, Veterans Health Administration. (2000). Major Depressive Disorder (MOD) clinical practice guidelines: Module A. Primary Care. Retrieved March 23, 2005, from http://www.oqp.med.va.gov/cpg/MDD/MDD_Base.htm These guidelines were developed for clinicians by the Department of Veterans Affairs and the Department of Defense. They draw heavily from the American Psychiatric Association and Agency for Health Care Policy and Research Clinical Practice Guideline No. 5: Depression in Primary Care. The guidelines include information on assessment and treatment of potentially suicidal patients, patient handouts on depression, and guidelines for treatment of depression. The guidelines, supporting documents, and tools are available online at the URL listed above.

Quinnett, P. (2000) Counseling suicidal people: A therapy of hope. Spokane, WA: QPR Institute. Retrieved March 23, 2005, from http://www.qprinstitute.com This book was written for therapists, mental health workers, physicians, nurses, and others who are not clinical suicide counselors, but who might find themselves counseling people at risk of suicide. It provides tools and strategies for risk assessment and intervention.

Sharp, L. K., & Lipsky, M. S. (2002). Screening for depression across the lifespan: A review of measures for use in primary care settings. American Family Physician, 66(6), 1001-1008. Retrieved March 23, 2005, from http://www.aafp.org/afp/20020915/1001.html

Stovall, J., & Domino, F. J. (2003). Approaching the suicidal patient. American Family Physician, 68(9), 1814-1818. Retrieved March 23, 2005, from http://www.aafp.org/afp/20031101/1814.html

Books

Berman, A.L., Jobes, D.A., Silverman, M.M. (2006). Adolescent Suicide: Assessment and Intervention (2nd edition). Washington, D.C.: American Psychological Association Press.

Hawton, K., & van Heeringen, K. (Eds.). (2000). International handbook of suicide and attempted suicide. Chichester, UK: John Wiley and Sons.

Jacobs, D. (Ed.). (1999). The Harvard Medical School guide to suicide assessment and intervention. San Francisco: Jossey-Bass. Maris, R, Berman, A, and Silverman, M.M. (2000) Comprehensive Textbook of Suicidology. NY: Guilford Publications.

Articles

Center, C., Davis, M., Detre, T., Ford, D. E., Hansbrough, W., Hendin, H., et al. (2003). Confronting depression and suicide in physicians: A consensus statement. Journal of the American Medical Association, 289(23), 3161-3166.

Hamilton, N. G. (2000). Suicide prevention in primary care. Careful questioning, prompt treatment can save lives. Postgraduate Medicine, 108(6), 81-84, 87. Retrieved March 23, 2005, from http://www.postgradmed.com/issues/2000/11_00/hamilton.htm

Rutz, W. (2001). The role of primary physicians in preventing suicide: Possibilities, short-comings, and the challenges in reaching male suicides. In D. Lester (Ed.), Suicide prevention: Resources for the millennium (pp. 173-188). Philadelphia: Brunner-Routledge.

Videos

American Foundation for Suicide Prevention [Writer] & Kingsley Communications [Producer]. (1999). The suicidal patient: Assessment and care [Motion picture]. Available from the American Foundation for Suicide Prevention at http://www.afsp.org/survivor/doctor.htm.

General Resources on Suicide and Suicide Prevention

American Association of Suicidology (AAS) (http://www.suicidology.org). The American Association of Suicidology is a nonprofit organization dedicated to the understanding and prevention of suicide. It promotes research, public awareness programs, public education, and training for professionals and volunteers and serves as a national clearinghouse for information on suicide.

American Foundation for Suicide Prevention (AFSP) (http://www.afsp.org). The American Foundation for Suicide Prevention (AFSP) is dedicated to advancing our knowledge of suicide and our ability to prevent it. AFSP's activities include supporting research projects; providing information and education about depression and suicide; promoting professional education for the recognition and treatment of depressed and suicidal individuals; publicizing the magnitude of the problems of depression and suicide and the need for research, prevention, and treatment; and supporting programs for suicide survivor treatment, research, and education.

Depression and Bipolar Support Alliance (DBSA) (http://www.dbsalliance.org) is a patient-directed organization focusing on depression and bipolar disorder. The DBSA website includes resources that can be used to locate professional help or support groups, a wide selection of educational brochures on depression, bipolar disorder, and suicide prevention, and an online bookstore. The DBSA supports more than 1,000 peer-led support groups across the nation. These support groups can be located by using DBS's website or calling (800) 826-3632.

National Alliance for the Mentally Ill (NAMI) (http://www.nami.org) is a nonprofit, grassroots, self-help, support and advocacy organization of consumers, families, and friends of people with severe mental illnesses, such as schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, panic and other severe anxiety disorders, autism and pervasive developmental disorders, attention deficit/hyperactivity disorder, and other severe and persistent mental illnesses. NAMI has local and state affiliates in every state that can provide support and education. NAMI also provides information and referrals through its Information Helpline which can be reached at (800) 950-NAMI (6264). Hearing impaired callers should call the TTY number at (703) 516-7227 or toll free at (888) 344-6264.

National Center for Injury Prevention and Control (http://www.cdc.gov/ncipc/). The National Center for Injury Prevention and Control (NCIPC), located at the Centers for Disease Control and Prevention, is a valuable source of information and statistics about suicide, suicide risk, and suicide prevention. To locate information on suicide and suicide prevention, scroll down the left-hand navigation bar on the NCIPC website and click on "Suicide" under the "Violence" heading.

National Mental Health Association (NMHA) (http://www.nmha.org/index.cfm) is a nonprofit organization addressing mental health and mental illness. Information available on the NMHA website includes fact sheets on depression, bipolar disorder, anxiety, substance abuse, and suicide; FAQs for consumers of mental health services; and a list of local affiliates who can be of assistance in finding mental health services in your area.

National Mental Health Consumers' Self-Help Clearinghouse (http://www.mhselfhelp.org) is a consumer-run national technical assistance center serving the mental health consumer movement. Among the resources available on the Clearinghouse Web site is a directory of mental health services that have significant consumer input (that is, input from people who use mental health services).

National Suicide Prevention Lifeline (http://www.suicidepreventionlifeline.org). The National Suicide Prevention Lifeline provides immediate assistance to individuals in suicidal crisis by connecting them to the nearest available suicide prevention and mental health service provider through a toll-free telephone number: (800) 273-TALK (8255). Technical assistance, training, and other resources are available to the crisis centers and mental health service providers that participate in the network of services linked to the National Suicide Prevention Lifeline.

National Mental Health Information Center (http://www.mentalhealth.samhsa.gov/cmhs/) provides information on mental health and recovery for both professionals and the general public. This website includes Consumer/Survivor resources:

• a Mental Health Services Locator featuring state directories of mental health and substance abuse treatment facilities and mental health services
• Consumer/Survivor Publications (in the Publications menu at http://store.mentalhealth.org/publications/browse.asp).

Suicide Prevention Action Network USA (SPAN USA) (http://www.spanusa.org). Suicide Prevention Action Network USA (SPAN USA) is the nation's only suicide prevention organization dedicated to leveraging grassroots support among suicide survivors (those who have lost a loved one to suicide) and others to advance public policies that help prevent suicide.

Suicide Prevention Resource Center (SPRC) (http://www.sprc.org). The Suicide Prevention Resource Center (SPRC) provides prevention support, training, and materials to strengthen suicide prevention efforts. Among the resources found on its website is the SPRC Library Catalog, a searchable database containing a wealth of information on suicide and suicide prevention, including publications, peer-reviewed research studies, curricula, and web-based resources. Many of these items are available online.