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Risk Factors Suicide

Risk Factors Suicide

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Published by Ayedh Alkhadem

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Published by: Ayedh Alkhadem on Dec 13, 2010
Copyright:Attribution Non-commercial


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Suicidality and Suicide in Primary Care: IntroductionIn those with major depression, the risk for suicide is increased 20-foldcompared with the general population.[1] A history of major depression ispresent in about 60% of those who complete suicides. An estimated 8% of those with major depression attempt suicide at some time during theirlifetime. This rate is increased in those with comorbid anxiety disorders (eg,25% with comorbid panic disorder and 38% in those with comorbidposttraumatic stress syndrome disorder).[2] About 31,000 people in theUnited States and 1 million worldwide die by suicide each year, and650,000 people in the United States are treated emergently following asuicide attemptShould You Ask About Suicidal Ideation?Physicians might be hesitant to inquire about suicidal thoughts, worriedthat inquiry might lead to suicide attempts. However, this has not beendemonstrated. In contrast, patients with such thoughts often seek theopportunity to discuss them, but may not verbalize their concerns withoutbeing prompted. The initiation of an office visit might be the only clue of suicidality. Although patients may be reluctant to divulge their intent tocommit suicide, if asked, patients with suicidal ideation usually will tell theirphysicians about such thoughts.[4]Recognizing the suicidal patient can be a challenge in primary care settings.No studies have demonstrated that screening for suicidality in primary caresettings reduces completed suicides or attempts.[5] Depression screeningand severity assessment instruments such as the Patient HealthQuestionnaire (PHQ)-9 and Quick Inventory of Depressive Symptomatology(QIDS) include questions about suicidal ideation ("Thought that you wouldbe better off dead or hurting yourself in some way?") that can triggerfurther inquiry by the physician. However, because we do not haveinstruments that adequately predict which patients with suicidal thoughtswill attempt suicide, once they are recognized, further inquiry andphysician judgment should determine any intervention
Risk Factors: What to Look Out For
An understanding of the risk factors for suicide can facilitate therecognition of high risk patients, and help in their assessment. Patientcharacteristics that increase suicide risk include:
Past attempts
: Half of suicide completers attempted suicide previously and1 out of 100 suicide attempt survivors die by suicide within the next year, arisk 100-fold greater than that in the general population.[6]
: Patients with multiple psychiatric conditions appear to be athigher risk than those with uncomplicated depression or an anxietydisorder.[7] Psychiatric disorders most frequently associated with suicideinclude depression, bipolar disorder, alcoholism or other substance abuse,schizophrenia, personality disorders, anxiety disorders (including panicdisorder), posttraumatic stress disorders, and delirium.[8,9] Anxietydisorders double risk for suicide attempt (odds ratio = 2.2)[10] but acombination of depression and anxiety greatly increases the risk (odds ratio= 17).[9] In depressed patients, comorbid personality disorder alsocorrelates strongly with suicide attempts. In addition, 20% to 25% of suicidecompleters are intoxicated at the time.[3]
Age, sex, and race
: Although young adults attempt suicide more often thanolder adults, the risk for completed suicide increases with age.[11] Men are3 times more likely to complete suicide, although women attempt suicide 4times more often than men.[12] These differences are the result of thelethality of the chosen method (eg, firearms) more than to a differenceacross age or sex in completion rates for a particular method.[13] Whitepeople complete about 90% of suicides in the United States; 72% are bywhite men.
Work status
: Unemployed and unskilled individuals are at increased riskcompared to those employed and skilled; occupational failure may lead tohigher risk. Physicians, particularly female physicians, may be at increasedrisk; a 25-study meta-analysis yielded a suicide rate ratio for female
physicians of 2.3 and for male physicians of 1.4 compared with the generalpopulation.[14]
: Impulsivity increases the likelihood of acting on suicidalthoughts, and the combination of hopelessness, impulsivity, and substanceabuse-related disinhibition may be particularly lethal.[3] This combinationoccurs most frequently in young adults.
: Medical illness, including chronic pain, chronic disease, and recentsurgery increases suicide risk.[3] HIV infection by itself does not increaserisk.[15]
Family factors:
Having a first-degree relative who committed suicideincreases risk sixfold. The heritability of suicide is in the 30% to 50% range,although it is uncertain whether genetic makeup contributes to theunderlying psychiatric disorder or to the suicide itself.[3] Individuals whohave never married are at the highest risk for completed suicide, followedin descending order by those who are widowed, separated, or divorced;married without children; and married with children. Risk also increases inpatients who live alone, who have lost a loved one, or who haveexperienced a failed relationship within one year.[16] The anniversary of asignificant loss is also a time of increased risk. Having a spouse whocommitted suicide increases the risk for suicide in the survivor.[17]Abuse and other adverse childhood experiences increase the risk for suicidein adults, at least partially mediated by the presence of alcoholism,depression, and illicit drug use, which also are strongly associated withadverse events in childhood.[3]
Access to means
: Of all suicides in the United States, 57% -- and 62% inmen -- are caused by a firearm, with rates increased 4- to 10-fold inadolescents who live in a household with a gun.[18] The second leadingmethods of suicide in the United States are hanging for men and poisoningfor women.

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