Assessment of suicide risk

Suicide risk assessment is ethically complex: the concept of "imminent suicide" (implying the foreseeability of an inherently unpredictable act) is a legal construct in a clinical guise, which can be used to justify rationing of emergency psychiatric resources or intrusion into patients' civil liberties. Accurate and legally defensible risk assessment requires that a clinician integrates clinical judgement with the latest evidence-based practice, although accurate prediction of low base rate events such as suicide is inherently difficult and prone to false positives. To ensure an evidence –based practice in the mental health unit, Cutcliffe recommends that nurses use a risk assessment tool, such as Nurses’ Global Assessment of Suicide Risk (NGASR), which will help them to spot factors that are linked with high risk of suicide. According to Cutcliffe, a suicide risk assessment tool not only provides evidence based practice, but also helps inexperienced mental health nurses to build up their clinical judgment.

In practice
There are risks and disadvantages to both over-estimation and under-estimation of suicide risk. Over-sensitivity to risk can have undesirable consequences, including inappropriate deprivation of patients’ rights and squandering of scarce clinical resources. On the other hand, underestimating suicidality as a result of a dismissive attitude or lack of clinical skill jeopardizes patient safety and risks clinician liability.

Key areas to be assessed include the person's predisposition to suicidal behavior; identifiable precipitant or stressors such as loss of job, recent death of a loved one and change of residence(Seaward 2006); the patient’s symptomatic presentation; presence of hopelessness; nature of suicidal thinking; previous suicidal behavior; impulsivity and self-control; and protective factors. Suicide risk assessment should distinguish between acute and chronic risk: acute risk might be raised because of recent changes in the person's circumstances or mental state, while chronic risk is determined by a diagnosis of a mental illness, and social and demographic factors. Bryan and Rudd (2006) suggest a model in which risk is categorized into one of four categories: Baseline, Acute, Chronic high risk, and Chronic high risk with acute exacerbation. Risk level can also be described as Nonexistent, Mild, Moderate, Severe, or Extreme, and the clinical response can be determined accordingly.

Age
In the USA, the peak age for suicide is early adulthood, with a smaller peak of incidence in the elderly.

Sex
China and São Tomé and Príncipe are the only countries in the world where suicide is more common among women than among men.

In the USA, suicide is around 4.5 times more common in men than in women. Gelder,Mayou and Geddes(2005) reported that women are more likely to commit suicide by taking overdose of drugs than men. Transgendered individuals are at particularly high risk.

Ethnicity and culture
In the USA, white Americans and Native Americans have the highest suicide rates, black Americans have intermediate rates and Hispanic people have the lowest rates of suicide. However, Native American males in the 15-24 age group have a dramatically higher suicide rate than any other group. A similar pattern is seen in Australia, where Aboriginal people (especially young Aboriginal men) have a much higher rate of suicide than white Australians, a difference which is attributed to social marginalization, trans-generational trauma, and high rates of alcoholism.

Marital status
Unmarried men and divorced or widowed women are at highest risk. Single, white, older males are at highest risk.

Sexual orientation
There is evidence of elevated suicide risk among gay and lesbian people. Homosexual females are at the greatest chance to attempt suicide in comparison to homosexual and straight males and straight females; however, homosexual males are at greatest risk to succeed.

Biographical and historical factors
The literature on this subject consistently shows that a family history of committed suicide in first-degree relatives, adverse childhood experiences (parental loss and emotional, physical and sexual abuse), and adverse life situations (unemployment, isolation and acute psychosocial stressors) are associated with suicide risk.

Recent life events can act as precipitants. Significant interpersonal loss and family instability, such as bereavement, poor relationship with family, domestic partner violence, separation, and divorce have all been identified as risk factors. Financial stress, unemployment, and a drop in socioeconomic status can also be triggers for a suicidal crisis. This is also the case for a range of acute and chronic health problems, such as pain syndromes, or diagnoses of conditions like HIV or cancer.

Mental state
Certain clinical mental state features are predictive of suicide. An affective state of hopelessness, in other words a sense that nothing will ever get better, is a powerful predictive feature. High risk is also associated with a state of severe anger and hostility, or with agitation, anxiety, fearfulness, or apprehension. Specific psychotic symptoms, such as grandiose delusions, delusions of thought insertion and mind reading are thought to indicate a higher likelihood of suicidal behavior. Command hallucinations are often considered indicative of suicide risk, but the empirical evidence for this is equivocal.

The primary and necessary mental state called idiozimia by Federico Sanchez (from idios=self and zimia=loss) followed by suicidal thoughts, hopelessness, loss of will power, hipocamppal damage due to stress hormones, and finally either the activation of a suicidal belief system, or in the case of panic or anxiety attacks the switching over to an anger attack are the converging reasons for a suicide to occur.

Suicidal ideation
Suicidal ideation refers to the thoughts that a person has about suicide. Assessment of suicidal ideation includes assessment of the extent of preoccupation with thoughts of suicide (for example continuous or specific thoughts), specific plans, and the person's reasons and motivation to attempt suicide.

Planning
Assessment of suicide risk includes an assessment of the degree of planning, the potential or perceived lethality of the suicide method that the person is considering, and whether the person has access to the means to carry out these plans (such as access to a firearm). A suicide plan may include the following elements: timing, availability of method, setting, and actions made towards carrying out the plan (such as obtaining medicines, poisons, rope or a weapon), choosing and inspecting a setting, and rehearsing the plan). The more detailed and specific the suicide plan, the greater will be the level of risk. The presence of a suicide note generally suggests more premeditation and greater suicidal intent. The assessment would always include an exploration of the timing and content of any suicide note and a discussion of its meaning with the person who wrote it.

Motivation to die
Suicide risk assessment includes an assessment of the person's reasons for wanting to commit suicide. This includes recent triggering events, and beliefs about death.

Other motivations for suicide
Suicide is not motivated only by a wish to die. Other motivations for suicide include an expression of anger or a desire for revenge on those who have hurt the person; and a person suffering from a terminal illness may intend to commit suicide as a means of managing physical pain and/or their way of dealing with possible future atrophy or death.

Reasons to live
Balanced against reasons to die are the suicidal person's reasons to live, and an assessment would include an enquiry into the person's reasons for living and plans for the future.

Past suicidal acts
People who commit suicide will often have a history of past self harm or suicide attempts. The level of suicidality is predicted by the nature of past suicide attempts, taking into consideration factors such as lethality, planning, and efforts made to conceal the attempt. However, there are people who commit suicide the first time they have suicidal thoughts and there are many who have suicidal thoughts and never commit suicide.

Suicide risk and mental illness
All major mental disorders carry an increased risk of suicide. However, 90% of suicides can be traced to depression, linked either to manic-depression (bipolar), major depression (unipolar), schizophrenia or personality disorders, particularly borderline personality disorder. Comorbity of mental disorders increases suicide risk, especially anxiety or panic attacks.

Anorexia nervosa has a particularly strong association with suicide: the rate of suicide is forty times greater than the general population. The lifetime risk of suicide was 18% in one study, and in another study 27% of all deaths related to anorexia nervosa were due to suicide.

The long-term suicide rate for people with schizophrenia was estimated to be between 14 and 22%, but a more recent meta-analysis has estimated that 4.9% of schizophrenics will commit suicide during their lifetimes, usually near the illness onset. Risk factors for suicide among people with schizophrenia include a history of previous suicide attempts, the degree of illness severity, comorbid depression or post-psychotic depression, social isolation, and male gender. The risk is higher for the paranoid subtype of schizophrenia, and is highest in the time immediately after discharge from hospital.

While the lifetime suicide risk for mood disorders in general is around 1%, long-term follow-up studies of people who have been hospitalized for severe depression show a suicide risk of up to 13%. People with severe depression are 20 times more likely and people with bipolar disorder are 15 times more likely to die from suicide than members of the general population. Depressed people with agitation, severe insomnia, anxiety symptoms, and co-morbid anxiety disorders are particularly at-risk. Antidepressants have been linked with suicide as Healy (2009)stated that people on antidepressant have the tendency to commit suicide after 10–14 days of commencement of antidepressant.

People with a diagnosis of a personality disorder, particularly borderline, antisocial or narcissistic personality disorders, are at a high risk of suicide. In this group, elevated suicide risk is associated with younger age, comorbid drug addiction and major mood disorders, a history of childhood sexual abuse, impulsive and antisocial personality traits, and recent reduction of psychiatric care, such as recent discharge from hospital. While some people with personality disorders may make manipulative or contingent suicide threats, the threat is likely to be non-contingent when the person is silent, passive, withdrawn, hopeless, and making few demands.

A history of alcohol abuse and alcohol dependence is common among people who commit suicide, and alcohol intoxication at the time of the suicide attempt is a common pattern.