The annual rate of suicide in the United States is about 11/100,000 accounting for at least 31,000 deaths annually. 3 There seem to be epidemiologic differences between suicide attempters and suicide completers. Suicide completers, for instance, are more likely than attempters to be older, male, living alone, or physically ill. These are high-risk patients who need to be carefully assessed. The ratio of attempted suicides to completed suicide is estimated to be about 40:1.

A suicide attempt is not a common accompaniment of the "downward" portion of the normal mood swings occasionally experienced by everyone. Only about 2 percent of the general population have seriously considered taking their lives and only about 1 percent have actually attempted suicide. Therefore, suicide attempters must be taken seriously. The attitude of the staff should be empathic; suicide precautions should be instituted; and, following medical management, the assessment of suicide risk should be carefully evaluated and documented. The decision to hold and hospitalize such patients should be given serious consideration.

Suicidal thinking is more frequent among women than among men and is associated with a clinical depression, social isolation, undesirable life events, and early parental loss. Suicidal thinking may precede an actual attempt by many months and may persist long after improvement in mental status and personal relationships.

Negative attitudes toward the suicide attempter have been documented among all types of emergency personnel: paramedics, nurses, and emergency physicians. A negative attitude intensifies a patient's already low self-esteem, thus increasing the risk of subsequent suicide and making it difficult to establish a therapeutic relationship.

Schizophrenia, substance abuse, and depression are psychiatric diagnoses that place a suicidal patient at relatively high risk. 3 Personality disorder and adjustment disorder implying a transient situational disturbance are frequent diagnoses in suicide attempters and are generally associated with relatively lower completion risk than the major psychiatric illnesses noted previously. Patients with these disorders still show a higher risk of completed suicide than the general population.

Drug overdose accounts for the overwhelming majority of all contemporary suicide attempts. Drugs used for suicide attempts tend to parallel prevailing prescribing patterns. Toxicity of the agent and the lethal intent of the patient help assess the relative risk. A patient taking a large dose of amitriptyline would be considered at greater risk than someone taking a few antihistamine tablets. Some patients may be relatively unaware of a drug's potential toxicity, however, and such knowledge and their continuing intent to die must be assessed by questions such as "Were you surprised to find yourself alive after taking the overdose?"

Violent attempts (shooting, jumping, hanging) are generally considered serious and a high-risk factor for a future attempt. A number of reports have described a "wrist-cutting syndrome" in young, unmarried women whose self-mutilation, although repetitive, has seldom been thought to be serious in intent. These acts usually have been carried out in a state of mounting tension with depersonalization followed by relief after self-mutilation. A significant number of "wrist slashers," or self-mutilators, however, whose cases have been followed for 5 to 6 years, have committed suicide.

In determining suicide risk, a general rule is that the risk of a successful suicide rises with advancing age. Men are two to three times more likely than women to complete suicide, whereas women are two or three times more likely than men to attempt suicide. Patients who are single, divorced, separated, widowed, or unemployed are at higher risk than those who are married and employed.

A psychotic patient who attempts suicide requires careful observation, whatever restraint necessary, and evaluation by a psychiatrist. A psychotic patient may respond unpredictably to distorted perceptions in a fearful or driven manner.

Secondary gain is a term that indicates that while the primary motive for a suicide attempt appears to be death, the attempt may meet another need such as attention or a plea for emotional help. When such needs are met by the attempt, a secondary gain is achieved and the risk of subsequent suicide attempt is lessened momentarily. It is dangerous, however, to assume that secondary gain is the cause of a suicide attempt with an initial evaluation in an emergency department. All suicide behaviors should be taken seriously.

Perhaps the most important part of the assessment of the suicide attempter is a determination of the patient's feelings and thoughts at the time of the interview. The patient who experiences helplessness, exhaustion, overwhelming depression, and a clear expression of intent to die certainly remains at high risk. If a patient expresses continuation of such feelings at the time of the interview, the physician has sufficient evidence that the patient needs psychiatric consultation immediately. Some patients, however, seem to equate self-injury with other forms of emotional discharge such as crying, talking to a friend, or becoming inebriated. They do not perceive the event as an attempt to end their life. When asked about their feeling at the time of the attempt, such patients may indicate that they were angry or vengeful. Attitudes and affect that generally indicate a good prognosis at the time of the interview are anger, remorse, or embarrassment. A patient who sits quietly, refusing to provide additional information to an examiner, should be considered at high risk. Feelings of hopelessness, helplessness, or exhaustion seem to be among the clearest indicators of long-term suicidal risk in patients hospitalized at one time for depression.

Patient disposition can be aided by estimating the lethality of the attempt and the likelihood of rescue. When there is a high likelihood of rescue and low lethality, a patient is considered at lower risk than in the reverse situation. A patient who makes a hanging attempt in a desolate wooded area is at greater risk than a person who takes a handful of relatively nontoxic pills in front of witnesses.

Patients who have made previous suicide attempts have traditionally been considered to be at greater risk for future suicide. Prior attempts seem a particularly ominous sign, particularly if the intensity and apparent lethality of the suicide attempts escalate with each subsequent attempt.

A "No Harm Contract"4 is very useful in the emergency department in evaluating suicidal risk. The "No Harm Contract"4 is a verbal or written agreement, initiated by the emergency room physician or psychiatrist, in which the suicidal patient is asked to agree not to harm or kill himself or herself for a particular period of time. This can be therapeutic, helping to reveal the intent of the patient and reduce it. It can also be diagnostic in assessing the nature and severity of a patient's suicidality. It can uncover specific issues precipitating suicidal thoughts and the ability of the patient to contract for safety.

A very difficult decision in the emergency department is when to discharge a child or adolescent patient who has expressed suicidal thoughts or behavior. Consideration of the following criteria is suggested before discharging a child or adolescent patient with suicidal ideation or behavior from the emergency department:5

1. The patient must not be imminently suicidal.

2. The patient must be medically stable.

3. The patient and the parents agree to return to the emergency department if suicidal intent recurs.

4. The patient must not be intoxicated, delirious, or demented.

5. Potentially lethal means of self-harm have been removed.

6. Treatment of underlying psychiatric diagnoses has been arranged.

7. Acute precipitants to the crisis have been addressed and attempts been undertaken to resolve them.

8. The physician believes that the patient and family will follow through on treatment recommendations.

9. The patient's caregivers and social supports are in agreement with the discharge plans.

Adolescents who complete suicide are more likely to have had histories of substance or drug abuse, disruptive disorders, anxiety, mood disorder, or schizophrenia. Precipitating events are usually stressors such as disciplinary crises, being in trouble with the law or at school, or the loss of a relationship. 6

A summary of high-risk and low-risk suicide profiles is presented in T§Me..,.2§1-.4..

TABLE 281-4 Evaluation of Suicide Risk in Adults and Adolescents

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