To Be, or Not To Be: Suicide Risk Factors and Prevention

Published February 19^th, 2010, 2:10 PM

One of the most famous discussions regarding suicide is elaborated in the soliloquy of Shakespeare's brooding prince, Hamlet. Contemplating his own death, he ponders:

To be, or not to be: that is the question:
Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,
And by opposing end them? To die: to sleep;
No more; and by a sleep to say we end
The heart-ache and the thousand natural shocks
That flesh is heir to, 'tis a consummation
Devoutly to be wish'd. To die, to sleep;
To sleep: perchance to dream: ay, there's the rub;
For in that sleep of death what dreams may come
When we have shuffled off this mortal coil,
Must give us pause:

Hamlet's dilemma is one faced by millions of people across the modern world. Distressed individuals from all socioeconomic backgrounds who attempt to take their own lives number up to 15 million per year, with roughly a million succeeding in their goal. The ramifications of these deaths are a major cause of concern to both the lay population as well as the healthcare professional whose duty is to safeguard the lives of others. Often a topic that people find uncomfortable to discuss, nonetheless, greater education of the known risk factors is pivotal to the prediction and consequently the prevention of suicide.

I received a call the other day from a good friend whose brother had suffered from Major Depression and Social Phobia for most of his life. He had been in psychiatric outpatient care for the last five years of his life, with little improvement in spite of medication and weekly psychotherapy. The reason for his call was that his brother had been increasingly fixated on the idea of ending his life. Disturbed by his morbid thinking, my friend became understandably angry and asked how he could even conceive of doing such an unthinkable thing to him and their mother. He replied that if he left them a note, it would soften the blow. It was at that point he called me to ask if he should be concerned for his brother's life and if so, what could he do.

In addition to having a Diagnosis of a Major Mood Disorder, his brother was unmarried, having recently broken up with his girlfriend a few months ago, was 42 years old and had recently lost his business that he had run for twenty years. What was also of note was that in spite of his family's repeated offers to come live with them so he could obtain more support, he chose to continue to live alone.

In the stratification of risk factors for attempting suicide, he met many of the criteria that would alarm most conscientious mental health practitioners. Currently, the hierarchy of risk factors for suicide is headed by the presence of:

• A major psychiatric illness (depression, schizophrenia, bipolar disorder, substance dependence)
• Co-morbid anxiety or personality disorders
• Serious medical illness
• Feelings of hopelessness and insomnia
• History of previous suicide attempts
• Direct or indirect communication of a wish to die
• Completed suicide of a first degree family member

The psychosocial risk factors are as follows:

• Traumatic or disturbing childhood events (separation, loss of caregivers, history of sexual or physical abuse)
• Isolative behavior (living alone, divorce, death of a partner)
• Loss of employment
• Sudden, severe negative life events
• Smoking

Finally, the demographic predictors are:

• Male gender (Women tend to have more attempts, whereas men have more completed suicides. For women the method of choice is by overdose, while men seem to prefer hanging or self-inflicted gunshot wound).
• Caucasian Race
• Age at adolescence or above 45
• Minority Groups (disaster victims, homosexuals, relatives of suicide victims)

Other factors to consider are whether or not the person has actually considered a method of carrying out the suicide and if they have access to the means of doing so (handgun in the house, access to medications to overdose, etc). If the person has already made an attempt, was there a high likelihood of being discovered and therefore rescued? Did they take themselves to the hospital following the attempt? Did they receive adequate treatment before being discharged if they did so?

It is interesting to note that 34-66% of suicide victims contact their primary medical doctor and 18-21% actually present to their psychiatrist in the four weeks before their deaths. However, in the week preceding their suicide, this number drops to 16-40% and 9-11% respectively. Another startling fact that was found is that suicide victims visited their GP three times more frequently than the average population - the unspoken cry for help. The suicide rate of patients recently discharged from a general hospitalization was three times the number of the general population. Of this number, 75% would be found to have a co-morbid depression or substance dependence that was undiagnosed and decidedly under treated. Even those seen by mental health practitioners are often missed, as the risk of suicide is also high in the immediate period following discharge from a psychiatric hospitalization, reduced aftercare being cited as the reason for this increased risk.

For those not involved in the mental health profession, the primary questions are "What do I look for?" and "What can I do?" If you suspect that someone close to you has an untreated psychiatric illness or substance abuse problem urge them to seek treatment. If they cannot, and you believe that they are a risk to themselves, depending on the particular laws of the state in which one resides, the person can be involuntarily hospitalized in order to ensure their safety and stabilize their condition. Behaviors that are suspicious include suddenly becoming happy and energized without an accompanying trigger. This change in affect can be the result of a feeling of closure and relief that comes from cementing the decision to end one's life. Another worrisome sign is when the individual begins making meticulous preparations to put their affairs in order (writing a will, selling a home, quitting a job, etc).

Though the risk factors for suicide are numerous, there are protective factors that exist. These include strong family and social support, pregnancy, having many children and strong religious beliefs. In addition, contrary to popular belief, discussing suicide does not "put the idea into a person's head" or increase the likelihood that they will make an attempt. Often times, the opposite is true and a frank, open discussion can be crucial in preventing suicide.

When my friend asked what I would do if it were my brother acting in this way, I posed the question, "What would happen if you air on the side of safety?" He replied that his brother would likely be upset with him, but nothing more than that. I then asked him, "What is the worse thing that could happen if you did nothing?" Without answering, he stated that he had to go in order to make some calls and his brother was hospitalized that very night. What surprised him most was that in spite of his prediction that his brother would be angry, he confided later to him that he was grateful for his help and support.

References:
1. Rihmer et. Al. Strategies for Suicide Prevention, Current Opinion in Psychiatry 2002, 15:83-87
2. Rihmer, Z. Suicide Risk in Mood Disorders, Current Opinion in Psychiatry 2007, 20:17-22