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Suicide

Approximately 25-30,000 people each year kill themselves. One of every eight attempts is successful. Suicide occurs in 1 per 100,000 people and increases in times of economic distress. Far more important is for you to know how to predict suicide because everybody else expects that you will be able to successfully assess who is at risk and who in fact will make a serious attempt. The trouble is that we have no way of predicting the future. Most people who complain about being suicidal donít kill themselves. Donít make attempts. Itís a very very common thought. If you had to hospitalize everybody who talked about common methods of suicide and physician assisted suicide.

There are things that we can pay attention to, when we are clinically evaluating. And this is the realm of the art of psychiatry rather than filling out pencil and paper forms, "Do you have this? Do you have this?" which is can you make a good assessment of how they really feel, what their affect of nature is. Do they really convince you that they are really in danger? Do you believe them? And is your judgment going to be adversely affected by your own thoughts and experiences? Do you like somebody too much? Do you despise somebody? Somebody comes in your office and saying, "What the hell should I talk to you for? You think youíre so smart .." and they go on and on and they get more irritating. And you say, "Next. Who cares? You want to die? Go kill yourself. Iíve got better things to do." That doesnít lead to good clinical care. A lot of people have been tempted to think, "Next." Or to say next. And thatís where being aware of the countertransference aspects of your care are very real. So the more you are aware of the risk factors, the more you can think about the questions to ask to find out whether you believe that they are truly at risk.

Given that, letís talk about what the risk factors are because they are all going to ask this question, "What are the risk factors for suicide and how prevalent are they?" and there are important categories to ask about in your review of the history. Fifty percent of completed suicides are a consequence of affective illness, primarily major depression. It is a really serious disease. And if you take the flip side of that and you say not how many patients who suicide had depression, what percent of people with affective illness like major depression.

The risk of suicide with depression increases when there is comorbid psychosis. And you need to screen for the criteria of depression in anybody that you are contemplating a suicide assessment. So the clinical criteria of sleep disturbance, decreased interest, presence of guilt, or preoccupation, decreasing energy, decreasing concentration, disturbed appetite, psychomotor agitation or retardation, thoughts of suicide or thoughts of death.

The next statistically major category is alcoholism and drug abuse. Twenty-five percent of completed suicides do so as a consequence of alcohol and drug abuse. Now you might be somewhat skeptical and say, "How can you distinguish between those with depression and those with substance abuse?" and you have to realize that you have to draw the line somewhere based upon what you think was really the reason for the suicide.Why would somebody with alcohol or substance abuse commit suicide? Well mainly because they are also depressed. They are intoxicated, they are more disinhibited and more apt to act on urges or thoughts that they have. So youíll see a lot of intoxicated people in emergency rooms as a result of that. In the morning you can make the determination that they are no longer intoxicated and no longer suicidal.

People with thought disorders do suicide. Ten percent of suicides are a result of thought disorder-type schizophrenia and conversely, about 10% of people with schizophrenia will suicide. Fortunately schizophrenia does not have the prevalence that depression has or there would be more suicides in this country. The prevalence increases when there are hallucinations or delusions that would endanger somebody. One of the more striking cases: on February 6th, 1978. A World War II veteran who had previously been a prisoner of war in Germany who became absolutely convinced, over and above his usual paranoid psychosis, that the Gestapo had invaded Boston. That he knew that he would be taken prisoner again. He did not want to be taken prisoner so he took a long kitchen knife and stabbed himself in the abdomen, up to the hilt.

Character disorders only account for 5% of completed suicides, which I find truly remarkable since that accounts for 85-90%. And cynically you might say, "Well, thatís because they canít do anything right in these attempts." And these people probably do, with anger and depression and loneliness. Not to say that this is all types of character pathology. It is not the antisocial people most of us sees but the borderline personalities that we see. But they account for a lot of attempts, a lot of ideation but not as many completions. And they are often dysphoric and the question is, "How do you know when they are safe?" because something else could always happen. And they are often very impulsive. So you really have to know which aspect of their character you are dealing with at a given moment and what happens.

You also have to remember that a sense of humor becomes important. Itís not that we become totally insensitive and callous. Itís a defensive style meant to work with oneself in the face of all the horrors of people doing really bad things to themselves. Many people that successfully suicide have previously made an attempt. Fifty percent of people have made numerous attempts at suicide have made prior attempts. Men are more successful than women. Not because men are more successful in general, but because they tend to use more violent means. In certain states where there is equal access to handguns, the prevalence is much closer together between men and women.

Some people have organic brain syndrome, that is acute or chronic organic brain, delirium or dementia. They realize that they are losing their mind, see what life lies ahead and donít wish to be a burden to others and they decide that they are going to kill themselves because they donít want to end up being a dement, or ament. And old people with confusion make lethal or near-lethal attempts, because itís confusion. They forgot how much of their usual medicine they took so what was really accidental, over intentional, becomes difficult to figure out.

There are a few biological markers that are associated with suicide. I donít know anybody who is going to do a lumbar puncture on somebody in the emergency room to check their 5HT, their serotonin, their 5HIA levels to see whether it was too low so you can give them a serotonin-enhancing medicine to decrease their risk. But there is a biologic marker. Recent hospital discharges, especially from a psychiatric unit, is a risk factor. Now you might say, "Why would that be?" Some of the hypotheses include: just because someone is suicidal doesnít mean that they are stupid.

To review the statistical risks, completed suicide: 50% associated with affect illness, 25% with drug or alcohol abuse, 10% with schizophrenia and other thought disorders, 5% character disorders, 3% organic brain syndromes, and 2% we donít really know why they do it. Because we canít interview the patient to figure out.

Who do you need to evaluate? There are several basic categories. Everybody that has survived a suicide attempt should require an in-depth interview to figure out why they did it, whether they are still at risk and need therapy. People who complain about having suicidal thoughts or urges should be assessed. People who complain about other things but admit to suicidal thinking on direct questioning should have further inquiry. And people, even when they deny being suicidal, who, by their actions, are acting suicidal should be assessed. So if you hear about somebody is driving 100 miles an hour, has panic, with no seat belt and no headlights, they should be assessed.