This course offers a comprehensive review of suicide as well as elucidates its complex nature and offers best practices in assessment, management, and prevention. This course meets the Washington state suicide prevention training requirement for health professionals
After completing this course, the learner will:
Latin for “self-murder,” suicide is a psychiatric emergency that claims over 42,000 lives every year in the United States . It is a fatal act that represents a person’s desire to die. Suicide is almost always the result of mental illness, usually depression, and it is preventable when recognized early and treated effectively.
Suicide is ranked the 10th overall cause of death in the United States (Table 1). Suicide accounts for over 42,000 deaths per year while homicide accounts for around 20,000 . Estimates suggest that there is a 25:1 ratio of suicide attempts to completed suicides. Over the past century, these rates have remained constant, averaging 12 per 100,000 persons .
|Chronic lower respiratory diseases||147,101 deaths|
|Alzheimer’s disease||93,541 deaths|
|Diabetes||76, 488 deaths|
|Influenza and Pneumonia||55,227 deaths|
|Kidney Disease||48,146 deaths|
|Liver Disease||38,170 deaths|
|Parkinson’s disease||26,150 deaths|
|Pneumonitis due to solids and liquids||18,792 deaths|
Suicide is the deliberate act of taking one's own life; however, there are a variety of terms used to classify the range of suicidal-type behaviors (Table 2) . Suicide not only ends a patient’s life, it also can leave a devastating legacy to the patient’s loved ones and result in litigation against the provider.
|Aborted suicide attempt||Potentially self-injurious behavior with explicit or implicit evidence that the person intended to die but stopped the attempt before physical damage could occur.|
|Deliberate self-harm||Willful self-inflicting of painful, destructive, or injurious acts without the intent to die.|
|Lethality of suicidal behavior|
Objective danger to one's life associated with a suicide method or action. Lethality is distinct from and may not always coincide with an individual's expectation of what is medically dangerous.
|Suicidal ideation||Thought of serving as the agent of one’s own death. The seriousness of suicidal ideation may vary depending on the specificity of suicidal plans and the degree of suicidal intent.|
|Suicidal intent||Self-injurious behavior with a nonfatal outcome accompanied by explicit or implicit evidence that the person intended to die.|
|Suicide||Self-inflicted death with explicit or implicit evidence that the person intended to die.|
Clinicians should understand both protective and risk factors for suicide. Protective factors buffer individuals from both suicidal ideation and suicidal behaviors. Risk factors, on the other hand, encompass individual, relationship, community, and societal factors that increase a person's likelihood of attempting suicide.
The Centers for Disease Control (CDC) notes that protective factors have not been studied extensively, but it is still important for clinicians to understand them . Protective factors include:
Risk factors for suicide can be divided into two categories: high-risk and low-risk characteristics. High-risk characteristics include older than 45 years, male gender, alcohol dependence, violent behavior, previous suicidal behavior, previous psychiatric hospitalization . Low-risk characteristics include younger than 45 years, female gender, married, employed, and lack of previous mental health disorder or suicide attempt . Table 3 compares high and low-risk characteristics.
|Age||>45 years||<45 years|
|Marital Status||Divorced or widowed||Married|
|Physical Health||Chronic illness, hypochondriac, excessive substance intake||Good health, feels healthy, low substance use|
|Mental Health||Severe depression, psychosis, severe personality disorder, substance abuse, hopelessness||Mild depression, neurosis, normal personality, social drinker, optimism|
|Suicide attempt||Multiple, planned, rescue unlikely, specific wish to die, self-blaming, available lethal method||First attempt, impulsive, rescue inevitable, wish for change rather than wish to die, external anger, low lethality method|
|Personal resources||Poor achievement, poor insight, unstable affect||Good achievement, insightful, controllable affect|
|Social resources||Poor rapport, socially isolated, unresponsive family||Good rapport, socially integrated, concerned family|
In the United States, suicide rates are lowest in New Jersey for both genders; Montana and Wyoming have the highest for men, and Alaska and Idaho have the highest for women . International suicide rates range from 25 per 100,000 in Lithuania, South Korea, and Russia to 10 per 100,000 in Portugal and Australia . The Golden Gate Bridge, located in San Francisco, California, is the most common suicide site in the world. Over 1,600 suicides have been completed there since it was built in 1937.
Men are four times more likely to commit suicide compared with women, regardless of age, race, religion, or marital status . On the other hand, women experience suicidal thoughts and attempt suicide three times as often as men. The reason for this disparity appears to be related to the different ways men and women attempt suicide.
The rate of suicide increases as a person ages . Prior to puberty, suicide is extremely rare. For men, suicide rates are highest at age 45; for women they are highest after age 55. Elderly persons attempt suicide less often than younger persons, but they are typically more successful. Unfortunately, the suicide rate is rising quickly in younger populations. Today suicide is the third leading causes of death for those aged 15 to 24 years, followed by accidents and homicides .
Race and Religion
Caucasian men and women are three times more likely to commit suicide than African American men and women. Native American and Alaskan Native youth experience suicide rates much higher than the national average . Rates among immigrant are higher than those among citizens . In the United States, Protestants and Jews have higher suicide rates than both Catholics and Muslims. Overall, the level of orthodoxy and integration with society is a more accurate predictor of suicide than religion alone .
Married individuals with children are much less likely to commit suicide than single persons. Single, never-married individuals experience double the suicide rate compared with married persons . Divorce increases the risk of suicide; divorced men are three times more likely to commit suicide than divorced women. Homosexual men and women have higher rates than heterosexual persons whether married or single. Some individuals commit “anniversary suicides” on the day their family member or loved one died .
The risk of suicide increases as a person's socioeconomic status increases. In general, employment serves as a protective factor against suicide; however, certain occupations increase a person’s risk. High-risk occupations include healthcare provider, artist, mechanic, lawyer, and insurance agent. Unemployed persons are more likely to commit suicide than their employed counterparts. Suicide rates increase during economic recessions and decreased during economic booms .
Over 30 percent of people who commit suicide have seen a healthcare professional within the previous six months. Physical illness, in general, is a significant contributing factor in half of all suicides. Factors that specifically contribute to suicide include loss of mobility, disfigurement, and chronic pain. Especially when these impact personal relationships and occupational status. Persons on hemodialysis are at an increased risk as well .
Nearly 95 percent of those who commit or attempt suicide have a diagnosed mental health disorder. Major depression and other depressive disorders account for 80 percent of suicides; those with delusional depression are at the highest risk . Furthermore, schizophrenia accounts for 10 percent, and dementia or delirium account for the remaining five percent. Over one-quarter of those who commit suicide are dependent on alcohol at the time .
Suicide risk is evaluated through two means: screens and assessments. Suicide screening refers to the use of a standardized instrument or protocol used to identify those at risk for suicide . These screens can be completed as part of a comprehensive suicide assessment or separately. Suicide screens may be conducted orally (the screener asking questions), on paper, or on a computer .
Suicide assessment describes a comprehensive evaluation usually completed by a clinician to determine suicide risk and course of treatment . Sometimes assessments include screens but they may also include an open-ended interview and broader conversations with the individual’s friends, family, or other healthcare providers. Assessments encompass detailed evaluations of a person’s thoughts, behaviors, risk factors, protective factors, and medical and psychiatric history
Although screening scales can help facilitate conversation between patients and providers; expert panels have determined that they have limited value. The following panels have independently reviewed the value of screening for suicide risk :
In their publication, Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide, the VA/DoD) wrote, “suicide risk assessment remains an imperfect science, and much of what constitutes best practice is a product of expert opinion, with a limited evidence base” . In addition, the U.S. Preventive Service Task Force concluded that suicide screens often elicit a high rate of false positives, rendering them ineffective when used independent from a comprehensive assessment conducted by a professional .
During their work group on suicidal behaviors, the American Psychiatric association determined that “although suicide assessment scales have been developed for research purposes, they lack the predictive validity necessary for use in routine clinical practice. Therefore, suicide assessment scales may be used as aids to suicide assessment but should not be used as predictive instruments or as substitutes for a thorough clinical evaluation .”
Furthermore, in their report, Suicide and Suicide Attempts in Adolescents, the American Academy of Pediatrics stated, “no specific tests are capable of identifying a suicidal person” and “scales…tend to be oversensitive and under specific and lack predictive value .”
Even though screening for suicide using questionnaires has low predictive value, they can be useful when used in additional to a comprehensive suicide assessment. When choosing a suicide screen, consider the following :
Screens for Children and Adolescents
In their publication, Assessment of Suicidal Behaviors and Risk Among Children and Adolescents, the National Institute of Mental Health recommends four suicide screening instruments for children and adolescents :
The Beck Scale for Suicide Ideation (BSI) is a 21-question self-report questionnaire that is best used to detect and measure the severity of suicidal thoughts. The authors of this screen emphasize that if a person endorses any item on the BSI than a suicide assessment should immediately be initiated. The BSI is more thorough than other screens asking questions about the desire to live, suicidal ideation, duration and frequency of suicidal thoughts, and suicidal plan .
The Harkavy Asnis Suicide Scale (HASS) is a 21-item questionnaire used to gather information about a child's current and past suicidal behavior. This screen gathers demographic information, previous suicidal acts, the frequency of suicide-related behaviors in the previous two weeks, and recent substance misuse. The HASS is used most commonly in high school students and includes questions like, “Have you ever thought about killing yourself but did not actually try?” 
The Suicide Ideation Questionnaire (SIQ) is used to determine the severity of suicidal ideation. There is a 30-item and 15-item version, both designed for younger adolescents. The SIQ asks individuals to rate the severity of their suicidal ideation on a 7-point Likert scale. This screen is based on a hierarchy of seriousness of suicidality ranging from thoughts to death to attempting suicide. This screen does not assess previous or recent suicide attempts and should almost always be supplemented by a comprehensive suicide assessment .
The Suicidal Behaviors Questionnaire for Children (SBQ-C) is a 14 question screen designed to assess suicidal thoughts and behaviors in children and adolescents. It is a self-report tool designed to be easily understood by children and adolescents. Very little psychometric data is available for this questionnaire .
Screens for Adults
There are various suicide risk screens available for adults; however, it is important to remember screens do not replace a comprehensive suicide assessment conducted by a professional. Commonly used suicide screens for adults include:
Aaron Beck developed the Scale for Suicide Ideation (SSI) in 1979 to evaluate the intensity of suicidal thoughts. It includes 19 questions each scored 0, 1, or 2 based on severity. It places individuals into three categories: active suicidal desire, preparation, and passive suicidal desire. This scale was later revised and named the Modified Scale for Suicide Ideation (MSSI). This screen used a scale 0 to 3 increasing the ability to discriminate between those who are thinking about suicide and those who are likely to attempt . The Columbia-Suicide Severity Rating Scale (C-SSRS) used primarily in primary care settings, and it is available in over 100 different languages. The C-SSRS does not require mental health training to effectively administer and it provides criteria for next steps (e.g. referral to a psychiatric provider) based on the score . The Nurses’ Global Assessment of Suicide Risk includes 15 items that help assess a person’s risk of attempting suicide. It allows clinicians to quickly evaluate high and low-risk characteristics. Each item on the screen is supported by research; however, the screen as a whole has not been empirically tested .
The Columbia-Suicide Severity Rating Scale (C-SSRS) used primarily in primary care settings, and it is available in over 100 different languages. The C-SSRS does not require mental health training to effectively administer and it provides criteria for next steps (e.g. referral to a psychiatric provider) based on the score .
The Nurses’ Global Assessment of Suicide Risk includes 15 items that help assess a person’s risk of attempting suicide. It allows clinicians to quickly evaluate high and low-risk characteristics. Each item on the screen is supported by research; however, the screen as a whole has not been empirically tested .
A suicide assessment is a specific type of psychiatric evaluation aimed at determining a person’s suicidal risk and creating a specialized treatment plan. The five domains of suicide assessment include the current presentation of suicidality, psychiatric illness, history, psychosocial situation, individual strengths and weaknesses . These domains are summarized in Table 4.
|Current Presentation of Suicidality|
|Individual strengths and weaknesses|
During a suicide assessment, clinicians should also conduct a thorough psychiatric evaluation. This information should be obtained from either the patient or their family members and friends. The clinician must approach the situation with empathy and compassion. In the context of a suicide assessment, the purpose of the psychiatric evaluation is to :
Clinicians should begin by assessing current signs and symptoms of psychiatric disorders . They should pay close attention to signs of a depressive disorder and make note of any high-risk characteristics (Table 3). Clinicians should document previous psychiatric hospitalizations along with prior treatment for substance use disorders . Specific psychiatric symptoms that increase a person's risk of suicide include aggression, violence toward others, impulsiveness, hopelessness, agitation, psychic anxiety, anhedonia, global insomnia, and panic attacks.
Clinicians should obtain and document a thorough history of the patient’s previous suicide attempts, aborted suicide attempts, and self-harming behaviors . Do not forget, a previous suicide attempt is one of the strongest risk factors for another attempt. When possible, clinicians should contact the patient’s current primary care or psychiatric provider .
Clinicians should also inquire about the patient’s family history. Family dysfunction is linked to suicide and other self-harming behaviors . Clinicians must assess for a family history of suicide or psychiatric disorders. Clinicians should also document a history of familial conflict or separation, parental legal trouble, family substance abuse, domestic violence, and physical or sexual abuse .
Next, the clinicians should assess the patient’s current psychosocial situation . What are their current stressors? Have they experienced any recent interpersonal losses, financial difficulties, or changes in socioeconomic status? The clinician should document acute crises, chronic stressors, employment status, living situation, family constellation, and cultural or religious beliefs about suicide .
Substance abuse may contribute to suicide. When suspecting substance use disorder, please consider:
Finally, clinicians must appreciate the patient’s psychological strengths and weaknesses. These may include coping skills, personality traits, thinking style, and development needs. Patients at an increased risk of exhibit polarized thinking, closed-mindedness, perfectionism, and excessively high self-expectations .
Healthcare providers must directly ask patients about suicidal thoughts, plans, and behaviors; however, cultural and religious beliefs about death and suicide may present a patient from speaking openly about his or her thoughts. In this case, clinicians must seek out collateral sources such as spouses, friends, family members, clergy, or other healthcare providers .
Table 5 includes a list of questions that clinicians can use when inquiring about different aspects of suicide. Clinicians should follow these steps :
|Thoughts of self-harm and suicide|
|Previous suicide attempts|
Repeated suicidal thoughts and attempts
|Harm to others|
Strategies for screening and appropriate use of information gained through screening.
During and after conducting a suicide screen or assessment, the clinician should develop a strategy for treatment and management of potential suicidal behaviors. In their publication Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, the American Psychiatric Association defines six key components of the management of suicidal behavior :
First, the healthcare provider must focus on developing a strong therapeutic alliance with the patient . The clinicians should begin by building trust and establishing mutual respect. Only within a trusting relationship will patients feel comfortable discussing and addressing their suicidal ideation and behaviors. The ultimate goal of the patient-provider relationship is reducing the risk of suicide .
Next, the clinician must attend to the patient’s safety . Throughout the suicide assessment, the clinician may need to intervene directly in order to prevent the patient from harming him or herself. For example, the clinician may need to search the patient’s belongings for weapons, lighters, matches, medications, or other toxic substances. The healthcare provider may also determine that the patient needs constant observation by either another clinician or closed-circuit television .
After developing a therapeutic alliance and attending to the patient’s safety, the clinician must select the most appropriate treatment setting. The patient should always be treated in the least restrictive yet safest most effective setting . Table 6 provides the guidelines for determining when a patient needs inpatient psychiatric treatment .
Admission to an inpatient psychiatric hospital is usually indicated after a suicide attempt or an aborted suicide attempt . Admission may be necessary if the patient expresses suicidal ideation, has previous attempts, and has a diagnosed psychiatric disorder. Outpatient treatment is most beneficial for those with chronic suicidal ideation or who have a stable supportive living situation .
Next, clinicians must develop a plan of treatment . The treatment plan begins by ensuring the patient’s safety and selecting the appropriate treatment setting. After acute treatment, the patient should be referred to a psychiatric specialist such as a psychiatrist or a psychiatric nurse practitioner. These specialized clinicians will continue the patient’s care and ensure timely diagnosis and management of any underlying mental health conditions.
In the early phases of treatment, specialists will monitor the patient closely and prescribe specific treatments for symptoms such as anxiety, insomnia, and hopelessness. During the early stages of recovering from a suicide attempt, patients will be encouraged to undergo education and supportive psychotherapy.
Psychiatric specialists and primary care providers must coordinate their care to offer the best treatment to patients with suicidal behaviors. These patients are often complex, requiring an interdisciplinary team of healthcare professionals such as social workers, case managers, and psychiatric nurses.
When the patient agrees, education should be provided to his or her involved family members. It is important for family members to understand that psychiatric disorders are real and difficult illnesses that require special treatment. Friends and family should also learn about the role of psychological and social stressors that can precipitate or worsen suicidal behaviors.
Jack is a 47-year-old Caucasian male. He has a history of major depressive disorder without psychosis beginning in his early 20s that has been controlled with various antidepressants. He and his wife separated two months ago. Last week he lost his job after repeatedly arriving late. He currently resides in a hotel and is out of contact with his friends and family. Earlier in the evening, his wife called the police after receiving a text message from Jack where he said he wanted to kill himself. The police brought Jack to the emergency room stating that they found him in his hotel room with a gun and bottle of vodka. Jack appears disheveled, depressed, and withdrawn. He tells you his life is not worth living and he wants to end his life. He does express some desire to seek treatment but fears his situation is hopeless.
How to identify and select an appropriate resource
Within the mental health system, there are varying levels of care. These levels range from not at all restrictive (e.g. outpatient care) to very restrictive (e.g. acute inpatient) . The more restrictive services are reserved for the most acute cases, whereas the less restrictive services are for less acute cases.
Individuals require different levels of care at different times during their treatment depending on the severity of their symptoms or degree of occupational or social impairment . Levels of care in the mental health system include:
Inpatient treatment is the highest, most acute level of nursing and medical services. It is provided in a structured environment 24-hours a day. Patients have full and immediate access to healthcare providers, and they undergo extensive and comprehensive psychiatric treatment. Inpatient treatment may be sought voluntarily by patients or deemed medically necessary by a healthcare provider. Inpatient treatment generally lasts three to seven days .
Residential treatment is one level down from inpatient, and it is considered sub-acute. These patients have access to 24-hour skilled nursing care, and they often live on site through their recovery. They usually undergo treatment that combines medication with group and individual psychotherapy .
Partial hospitalization refers to an intensive, non-residential settings where patients receive care during the day but return to their home at night. They undergo structured medical and nursing care with services similar to inpatient psychiatric hospitals. Usually, in these settings, the patient receives medication treatment and participant in group psychotherapy .
Intensive outpatient treatment offers patients regular contact with mental health professionals, often multiple days per week. Patients in intensive outpatient programs receive care more often than those in general outpatient services but less often than those in partial hospital programs . Outpatient care, on the other hand, is the least restrictive form of mental health care. Patients often meet with their mental health provider in an office setting to undergo psychotherapy sessions and medication management .
After completing a suicide assessment, a qualified mental health clinician can determine the most appropriate level of care . Table 6 offers guidelines for determining the best treatment setting for a particular patient.
Following a suicide attempt, inpatient psychiatric treatment is recommended. Following an aborted suicide attempt, inpatient psychiatric treatment is most likely recommended, especially if the patient expresses regret surviving or a persistent internet to end their life. If the patient has minimal family or social support, is psychotic, or is declining any type of mental health care, they most likely require inpatient treatment .
Furthermore, inpatient psychiatric hospitalization may also be necessary for the presence of suicidal ideation [16, 17]. If a patient expresses suicidal thoughts and they have a history of previous attempts, the presence of another psychiatric disorder, and limited social support, they may require inpatient treatment. If the patient describes a specific plan with a high lethality, they almost always need hospitalization .
Partial hospitalization is appropriate for patients who do not require inpatient treatment but require more intensive services than available in outpatient settings . Because partial hospitalization is highly structured with both nursing and medical services, it is best for those experiencing suicidal ideation without a specific plan and with some social support. Importantly, when choosing partial over inpatient hospitalization, consider whether the patient has the capacity for reliable attendance. Partial hospitalization is also used as step-down from inpatient treatment to help patients transition to outpatient treatment [16, 17].
Outpatient mental health services are appropriate if patients are experiencing transient or mild suicidal ideation without a specific plan or intent to attempt . These patients should also have a stable and supportive living situation and be willing to cooperate with recommendations for follow-up.
|Table 6: Guidelines for Determining Treatment Setting |
Inpatient treatment recommended
After a suicide attempt or aborted suicide attempt if:
|Inpatient treatment might be necessary|
In the presence of suicidal ideation with:
|Outpatient treatment recommended|
After a suicide attempt or in the presence of suicidal ideation/plan when:
After a person has attempted suicide, they often require inpatient psychiatric treatment. Sometimes patients will agree to this treatment, while others will not. The Involuntary Treatment Act governs the psychiatric detainment against the will of the patient in the state of Washington. This law can be found under Title 71.05 of the Revised Code of Washington .
In Washington State, anyone who possesses first-hand knowledge of the patient can refer him or her for involuntary psychiatric treatment. A county designated mental health professional such as a psychiatric nurse practitioner or a psychiatrist must see the patient and complete a thorough evaluation. The criteria for commitment include :
If the county designated mental health professional determines that a person meets these criteria, they can authorize a 72-hour involuntary detention. The person will be sent to a psychiatric hospital. At a psychiatric hospital, the patient maintains their individual rights and are not presumed incompetent, meaning their information remains strictly confidential. The patient will receive the appropriate treatment.
After 72 hours, the patient can request legal counsel and a court evaluator if he or she remains unwilling to accept treatment on a voluntary basis. The court evaluator is usually a psychologist who will perform an independent assessment as to whether the patient meets the criteria for involuntary commitment. The patient's legal counsel will meet with the patient to represent his or her wishes during a formal hearing, called the Probable Cause Hearing.
During the Probable Cause Hearing, a judge will determine if there is enough evidence to warrant further involuntary treatment. This hearing can result in one of four decisions :
If the judge maintains the involuntary commitment, the patient will return to the psychiatric facility for at most 14 more days. If a county designated mental health professional determines the patient needs to remain at the facility even longer, they can file a 90-day petition, and the process starts over. If the judge rules in favor of a 90-day commitment, the patient is transferred to the Western State Hospital (adults) or Fairfax Hospital (children) .
Continuity of care when making referrals
In 2011, the Suicide Prevention Resource Center (SPRC) collaborated with the Substance Abuse and Mental Health Services Administration (SAMHSA) to review the research on suicide attempts occurring following a patient’s discharge from an emergency department or inpatient psychiatric hospital . They published their findings in a report titled, Continuity of Care for Suicide Prevention and Research.
In their report, both SPRC and SAMHSA found that many lives could be saved by improving the continuity of care between emergency department and psychiatric services . After patients are discharged from the emergency room and inpatient psychiatric hospitals, they must be effectively transitioned to outpatient psychiatric services. Continuity of care refers to linking providers in one setting to providers in another and ensuring that all clinical information is transferred correctly and smoothly .
Best practices for connecting a client or patient to a referral
Discharge plans for patients with suicidal thoughts or a recent suicide attempt should include making contact with their outpatient providers. This approach increases the patient's access to follow-up care and reduces their risk of relapse. As discharge plans are established, always consider the particular patient’s barriers to treatment such as financial or transportation challenges. Best practices for connecting a patient to a referral include :
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