Suicide
A patient who wants to take his or her own life challenges a physician’s fundamental purpose. Although the reason for the suicide attempt may not be immediately apparent, people rarely reach this decision easily. In fact, most suicidal patients are ambivalent about their decision to kill themselves; they want to escape an intolerable life situation, but at the same time, they have the often-unconscious desire to be saved from self-destruction. Because this desire leads most suicidal patients to visit a physician with vague physical complaints in the 6 months before the act, a primary care doctor is often in a unique position to save the patient.
table 14.1 RISK FACTORS FOR SUICIDE | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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People commonly make statements like, “I felt so sick I wanted to die” without suicidal intent. However, whenever such a statement is made to a physician, it must be taken seriously, particularly when the patient is physically ill, depressed, or otherwise emotionally impaired. Although no specific set of characteristics identify a suicidal patient, certain demographic, psychological, social, and physical factors have been associated with increased suicide risk (Table 14-1). No matter what risk factors are present, the physician’s good clinical judgment is the most important variable in identifying the patient at risk for suicide.
• PREVIOUS SUICIDAL BEHAVIOR
A serious earlier suicide attempt, particularly within the past 3 months, is the most significant risk factor for completed or “successful” suicide. Although there are many more attempts than actual suicides, approximately 30% of people who attempt suicide try it again, and 10% succeed. Characteristics of the previous attempt are important considerations in the assessment of future suicide risk. Clearly, the more potentially lethal the previous method used, the higher the future suicide risk. Means such as shooting or hanging oneself, jumping from a high place, or crashing one’s vehicle are more lethal than ingesting pills or slashing one’s wrists. The likelihood of rescue from the previous suicidal act is also important when assessing future risk. A suicide attempt is potentially more lethal if it takes place in a setting where the possibility of rescue is remote. Thus, patients who attempted suicide in an unfamiliar setting where no people were nearby are at higher risk than those who tried suicide in a familiar setting with people nearby (e.g., at home just before a family member was expected to arrive).
• DEMOGRAPHIC RISK FACTORS
In 2007, suicide was the 11th leading cause of death in the United States, after heart disease, cancer, stroke, chronic obstructive pulmonary disease, accidents, Alzheimer’s disease, diabetes mellitus, pneumonia, kidney disease, and sepsis. The suicide rate in the United States is approximately 12 per 100,000. This rate has been relatively steady for more than 40 years, and it falls in the midrange for developed countries. Scandinavia, Japan, Switzerland, Germany, Austria, and countries in Eastern Europe have suicide rates two times that of the United States. Spain, Italy, Ireland, Egypt, and the Netherlands have lower rates (less than 10 per 100,000) (Sadock & Sadock, 2007; Sadock, 2009).
 FIGURE 14-1. Suicide rates in men and women by age in the United States in 2007. (Source for data: Centers for Disease Control and Prevention. CDC health disparities and inequalities report—United States, 2011. MMWR. 2011;60,57.) |
Age
Suicide is rare in children. However, it is the third leading cause of death in adolescents aged between 15 and 19 years, following only accidents (first) and homicide (second). In part because teenagers are inclined to do what other teens do, teen suicide, like teen violence, tends to occur in clusters (Mckeown et al., 1998; Shafii & Shafii, 2002). In adulthood, suicide risk is positively associated with age and increases substantially after 55 years of age. In the elderly, suicide risk decreases as women age but increases as men age (Fig. 14-1); white men 65 years and older are more likely to commit suicide than any other group.
Sex and ethnicity
There are gender and ethnic differences in suicide rates. Although women attempt suicide four times more often than men do, men successfully commit suicide three times more often than women do. One reason for this difference is that men tend to use more violent and hence lethal means than women. Historically, African Americans have had lower suicide rates than white Americans. However, the race gap is narrowing among males aged between 15 and 19 years, particularly for suicide by gun
(Joe & Kaplan, 2002). Native-American and Inuit groups have high-suicide rates (Fig. 14-2), and immigrants to the United States have higher rates of suicide than the general population in both this country and their native countries.
(Joe & Kaplan, 2002). Native-American and Inuit groups have high-suicide rates (Fig. 14-2), and immigrants to the United States have higher rates of suicide than the general population in both this country and their native countries.
 FIGURE 14-2. Suicide rates by race/ethnicity in the U.S. in 2007. Rates for persons with unknown race/ethnicity were omitted due to unavailable population data. (Source for data: Centers for Disease Control and Prevention. CDC health disparities and inequalities report—United States, 2011. MMWR. 2011;60,57.) |
Marital status and religion
People with little social support are at higher risk for suicide than people who have strong social support systems, such as marriage and religion (Van Ness, and Larson 2002
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