Suicide

Suicide: Excerpt from The 5-Minute Pediatric Consult

Leonard J. Levine, MDJonathan R. Pletcher, MD

Suicide - BASICS

Suicide - description

• An intentional self-harming act that ends life.
• Attempted suicide occurs when the act does not succeed in its goal (also, failed or near-suicide).
• Suicidal behavior is any voluntary act that can potentially end one’s life.
• Suicidal ideation is defined as thoughts, with or without a specific plan, to end one’s life.

Suicide - general prevention

• Screening of all adolescents for suicidal thoughts and behaviors should occur at routine office visits and during evaluation of emotional distress or physical symptoms (e.g., chronic headache, abdominal pain). Screening should include the following:
  • Change in level of functioning in school, work, or home
  • Changes in mood or affect
  • Direct inquiry about suicidal ideation and plans
  • Exploration and discussion of coping strategies
  • Discussion of social support
• If suicidal ideation is reported, components of risk assessment include the following:
  • Frequency and timing of suicidal thoughts
  • Method of self-injury considered
  • Plan to follow through
  • History of past suicide attempt(s)
  • Consultation with a psychiatrist if there is any question of risk for suicide attempt

Suicide - epidemiology

• Suicide is the 3rd leading cause of death for the 10–14-, 15–20-, and 20–24-year-old age groups.
• Adolescent mortality from suicide tripled between the 1950s and the 1990s.
• Females attempt suicide at a rate 2–4 times that of males. Females are most likely to attempt suicide through ingestion.
• Males complete suicide at a rate 3–4 times that of females. Males are most likely to use more lethal methods, such as firearms and hanging, when attempting suicide.
• Completed suicide rates are highest in white and Native American adolescents. Suicide rates for black males 10–19 years old doubled between the years 1980 and 1995, but have since declined. Highest rates of suicide attempts have been reported in Hispanic females.
• Gay, lesbian, bisexual, and questioning youth report higher rates of suicide attempts than their heterosexual peers.

Suicide - incidence

• ~2,000 adolescents in the US die from suicide, and ~2 million attempt suicide annually.
• Overall, suicide accounted for 7.3 deaths per 100,000 persons aged 15–19 years in 2003 (11% of all deaths in this age group).
• In 2003, suicide accounted for 1.2 deaths per 100,000 persons aged 10–14 years (6% of all deaths in this age group), and for 12.0 deaths per 100,000 persons aged 20–24 years (12.5% of all deaths).
• In 2005, 17% of youth surveyed in grades 9–12 reported seriously considering suicide at some point in the preceding year: ~8% reported attempting suicide in the previous year, with 2.3% of youth having an attempt that required medical attention.

Suicide - risk factors

• Previous suicide attempt(s)
• Mood disorders
• Substance/Alcohol abuse
• Family history of suicide
• Family history of mental illness or substance abuse
• History of sexual or physical abuse
• Family conflict or disruption
• Presence of firearms in the home

Suicide - pathophysiology

• Decreased central serotonergic activity may result in aggressive or impulsive behaviors, which may be aimed at oneself.
• An underlying psychiatric or personality disorder acutely worsened by a stressful life event may trigger a suicidal act.
• Feelings of isolation and lack of external support (particularly from caregivers) may result in hopelessness and despair.
• Suicide may be an impulsive act designed to punish loved ones or express frustration or rage. All suicidal behavior must be carefully evaluated and taken seriously.

Suicide - etiology

Suicidal behavior in adolescents results from the interaction of longstanding individual and family conditions, social environment, and acute stressors:

• Psychiatric disorders:
  • Suicidal behavior is included in the diagnostic criteria for major depressive episode and borderline personality disorder (DSM-IV).
  • Additionally, psychotic disorders, conduct disturbance, adjustment disorder, and panic disorders have all been found to be associated with suicidal behavior.
• Intense emotional state, in particular shame or humiliation, can be “trigger events” for a suicidal act.
• Personality and social factors, such as antisocial behavior, aggressive or impulsive proclivities, and social isolation, can also contribute.

Suicide - DIAGNOSIS

Suicide - signs & symptoms

Suicide - history

• The provider should sensitively ascertain if the patient has a weapon or other method of self-harm.
• A comprehensive history should always be obtained or reviewed by a trained mental health worker. Components of a comprehensive history include:
  • Method and timing (particularly if method is ingestion)
  • Lethality of attempt (e.g., number of pills, seriousness of physical injury)
  • Circumstances of attempt (e.g., remote site, public display)
  • History of prior attempts
  • Level of planning of attempt
  • Current affect and psychological status (e.g., feelings and/or level of depression, hopelessness, impulsivity, self-esteem)
  • Family consistency and dynamics
  • Pharmaceuticals available at home; what is missing
  • History of interpersonal conflict or personal loss
  • Family history of suicide
  • History of substance use
  • History of psychological disorder or disease state
  • History of abuse, neglect, or incest
  • Social supports and coping strategies
  • Feelings of regret or continued desire for self-harm
• The following historical information increases the risk for a future, potentially lethal suicide attempt:
  • History of potentially lethal attempt
  • Family history of suicide or attempted suicide
  • Unstable family structure
  • Poor social support system, lack of feeling connected

Suicide - physical exam

• Even without a history of ingestion, closely observe vital signs, skin, mucous membranes, and pupils for evidence of toxidrome.
• Examine the skin for signs of physical abuse or self-mutilation.
• A complete neurologic examination is essential for the evaluation of intracranial processes, acute mental status changes, and ingestions.

Suicide - tests

Different laboratories offer different spectra and sensitivities in their toxicology screens.

Suicide - lab

• Serum and urine toxicology screens
• Urine pregnancy test to assess pregnancy as a potential precipitating factor and to recognize potential danger to the fetus
• Acetaminophen level, as it is highly hepatotoxic and is used frequently by teenagers
• EKG are indicated for many pharmacologic ingestions, including antidepressants and benzodiazepines.

Suicide - imaging

Abdominal plain film: If history of iron or vitamin ingestion, or severe trauma

Suicide - differencial diagnosis

• CNS trauma: Any insult to the cerebral cortex can result in disinhibitory behaviors.
• Psychiatric disorders, with particular attention to depression, personality disorder, and substance abuse
• Psychosocial trauma or maladjustment:
  • Emotional or physical abuse, with the suicide attempt being a way to gain attention, obtain help, or to serve as a means of escape
  • Feelings of isolation or abandonment, such as following the revelation of pregnancy or homosexuality

Suicide - TREATMENT

Suicide - initial stabilization

• Airway, breathing, and circulation (ABCs)
• Monitoring of behavior and vital signs if history of ingestion
• Decontamination of GI tract and circulation as indicated
• When available, a poison control center may be helpful with evaluation and treatment of most drug ingestions.
• Ongoing safety is of primary concern: Provide immediate physical protection (remove all weapons) and enforce around-the-clock observation.

Suicide - general measures

• Parents and professionals should avoid minimizing attempts as “not serious” or as “just seeking attention.”
• Psychiatric disposition should be determined by, or in conjunction with, a mental health professional. Considerations for admission include the following:
  • Historical factors indicating high risk for repeated attempt
  • Ongoing suicidal ideation and/or planning
  • Family instability and lack of support
  • Altered mental status
  • Lack of alternative interventions (e.g., intensive psychiatric follow-up, day treatment program)
• When discharge to a caregiver is being considered, the following minimal criteria should be in place at the time of discharge:
  • The patient expresses regret and denies ongoing suicidal thoughts.
  • The patient is medically stable.
  • The patient’s family is involved and reports understanding of the seriousness of the attempt.
  • The patient and parents agree to contact a health professional or go to the emergency department if suicidal intent recurs. The patient and family must have 24-hour access to mental health or physical health professionals.
  • The patient must not have impaired mental status (e.g., severely depressed, psychoses, delirium, intoxication).
  • Lethal methods of self-harm are not immediately available to the patient (e.g., guns, dangerous pharmaceuticals).
  • Follow-up and treatment of underlying psychologic disorders have been arranged. This ideally involves much more than providing a phone number to psychiatric services or asking the family to contact their insurer.
  • Acute precipitants and crises have been addressed.
  • Caregivers and patients are in agreement with the discharge plan.
  • Barriers to obtaining follow-up treatment, in particular insurance and fear of stigma, have been addressed and will not preclude the next step toward ongoing treatment.

Suicide - special therapy

In addition to medication, important psychiatric interventions include acute short-term inpatient psychiatric hospitalization, partial hospitalization (with intensive treatment and support), and outpatient therapy.

Suicide - medication

• For recent ingestions, GI decontamination with activated charcoal may be appropriate, as is the administration of pertinent antidotes (e.g., naloxone for opioids, N-acetylcysteine for acetaminophen).
• Although psychotherapy is an essential component to the care of the suicidal adolescent, pharmacotherapy with antidepressants can also play a role, especially given the high association with comorbid mood disorders.
  • Keep in mind when prescribing tricyclic antidepressants (TCAs) their high lethality potential.
  • SSRIs have been shown to be effective in treating depressive disorders in adolescents. Use of SSRIs in patients with the potential for suicidal behavior requires close monitoring. At least 3 currently marketed SSRIs that are approved for the treatment of depression in adolescents (venlafaxine, paroxetine, fluoxetine) have been shown to be associated with an increase in self-injurious behavior.

Suicide - FOLLOW UP

Long-term psychotherapy (individual and family therapy) is often needed for adolescents who attempt suicide. Improvement may be slow and punctuated by frequent setbacks.

Suicide - prognosis

• 20–50% of those attempting suicide will try again.
• Psychiatric hospitalization has not been shown to decrease risk of attempted suicide in patients with a history of mood disorder or substance abuse.
• Multiple reports show that adolescents who attempt suicide routinely terminate treatment after a few visits.

Suicide - complications

• Long-term organ damage or physical disability, depending on the method used
• Long-lasting emotional scars in families of victims, resulting from frustration, anger, and guilt
• Repeat suicide attempt or completion

Suicide - bibliography

1. American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry. 2001;40(7 suppl):24S–51S.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. 2005. Accessed (cited) September 22, 2006. Available from URL: www.cdc.gov/ncipc/wisqars
2. Gould MS, Greenberg T, Velting DM, et al. Youth suicide risk and preventive interventions: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2003;42(4):386–405.
3. Kennedy SP, Baraff LJ, Suddath RL, et al. Emergency department management of suicidal adolescents. Ann Emerg Med. 2004;43:452–460.

Suicide - CODES

Suicide - icd9

• 300.9 Suicide risk
• V62.84 Suicidal ideation
• E950–E959 Suicide and self-inflicted injury

Suicide - FAQ

• Q: Do I keep suicide attempts or plans confidential?
• A: No. The limits of confidentiality should be clearly outlined to patients and families at the 1st visit or early in the patient’s adolescence. These limits include anything that will directly place the patient’s life in danger, such as suicidal intent, ongoing or recent abuse, or homicidal intentions.
• Q: If I directly question my patients about suicide, won’t that put the idea in their head?
• A: No. In the majority of cases, patients will be relieved by having a professional who wants to talk about suicide. There is only risk in asking if nothing is done with the answer. Appropriate referral to mental health services or counseling can save patients’ lives.
• Q: Is a patient who reveals that they are cutting to relieve anxiety or tension actually suicidal?
• A: Certainly any adolescent who is practicing self-mutilation to cope with emotional distress is at risk of developing additional unhealthy coping behaviors. To date research and anecdotal evidence do not support a direct link between cutting and a hidden agenda toward suicide.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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