Suicide Statistics

Suicide is a significant public health concern. Approximately 44,965 Americans die by suicide each year [1]. This equates to approximately 123 suicides per day. Recent reports have indicated a 30% increase in suicide rates from 1999 to 2016 (10.5 per 100,000 to 13.4 per 100,000) [2]. Additionally, we know that suicide does not only affect those with a diagnosed mental health condition. The CDC data notes that approximately half of those who died by suicide between 1999 and 2016 did not have a known mental health condition [2]. Though a mental health condition can be a risk factor for suicide, other factors that can contribute to suicide include stress related to relationships, finances, jobs, housing, substance use, or physical health. The ubiquity of suicide and the increase in suicide rates over the last 17 years support the importance of community suicide education and consistent suicide assessment, intervention, and treatment among clinicians interacting with individuals at increased suicide risk.

Suicide Terminology

Prior to moving into the description of the components of a suicide assessment, it is important for clinicians to have a standard language when communicating about a patient’s suicide risk. Not doing so can result in problematic consequences (e.g., mislabeling and miscommunicating a patient’s statements regarding suicide, inaccurate treatment, inaccurate documentation). O’Carroll et.al. [3] developed a standard method of communicating that continues to be used today. The 6 terms identified include:

  1. Suicide — death from injury, poisoning, or suffocation where there is evidence that the injury was self-inflicted and that the decedent intended to kill himself/herself.
  2. Suicide attempt with injuries — An action resulting in nonfatal injury, poisoning, or suffocation where there is evidence that the injury was self-inflicted and that he/she intended at some level to kill himself/herself.
  3. Suicide attempt without injuries — A potential self-injurious behavior with a non-fatal outcome, for which there is evidence that the person intended at some level to kill himself/herself.
  4. Instrumental suicide related behavior — Potentially self-injurious behavior for which there is evidence that the person did not intend to kill himself/herself (zero intent to die) and the person wished to use the appearance of intending to kill himself/ herself in order to attain some other end (to seek help, to punish others, or to receive attention). Instrumental suicide-related behavior can occur with injuries, without injuries, or with fatal outcome (accidental death).
  5. Suicide threat — Any interpersonal action, verbal or nonverbal, stopping short of adirectly self-harmful act, that a reasonable person would interpret as communicating or suggesting that a suicidal act or other suicide-related behavior might occur in the near future.
  6. Suicidal ideation — Any self-reported thoughts of engaging in suicide-related behavior.

The above nomenclature reflects three essential elements of suicide behavior [4]: 1. outcome, 2. evidence of self-infliction, 3. evidence of intent to die by suicide. Consistency in the use of nomenclature ensures that communication between clinicians accurately identifies the nature of a patient’s suicide experience.

Having a consistent way of discussing and communicating about suicide is also helpful in demonstrating that mental health clinicians do not predict suicide but use reliable and consistent methods to understand and intervene (manage and treat) when suicide risk has been identified.

Suicide assessment is focused on explaining and estimating suicidality [5] by looking at different factors about a person, and using this information to guide treatment and management of suicidal thoughts and behaviors [5]. Remembering this important fact can reduce the clinician’s internal feeling of pressure and allow for them to appropriately assess and treat suicidal individuals.

An assessment involves a review of the following [6, 7, 8]:

  • Predispositions to suicidal behavior (demographics, history of psychological diagnoses, history of suicidal behavior, discharge from inpatient treatment, history of abuse)
  • Identifiable stressors
  • Current symptom assessment
  • Existence of hopelessness
  • Nature of current suicidal thinking and past suicidal behaviors
  • Subjective and objective measure of impulse control
  • Risk and protective factors
  • Determination of risk level and imminence
  • Identification of a clinically supported plan to address a patient’s suicidal thoughts/behaviors

Assessment

Literature supports a suicide assessment approach that gradually moves from lower intensity to higher intensity as one method of reducing patient anxiety and developing rapport. Bryan and Rudd [7] describe this as “a hierarchical approach” which “moves from identification of the precipitant to the patient’s symptomatic presentation, to hopelessness, to the ultimate nature of the patient’s suicidal thinking.” Gathering and understanding demographic information allows for the clinician to understand whether the patient falls within a category of individuals at greater risk of suicide (e.g., age, race, sex).

Demographics

In 2016, the highest suicide rate (19.72 per 100,000) was among adults between 45 and 54 years of age. The second highest rate (18.98 per 100,000) occurred in those 85 years or older. Younger groups have had consistently lower suicide rates than middle-aged and older adults. In 2016, adolescents and young adults aged 15 to 24 had a suicide rate of 13.15 per 100,000. In 2016, the highest U.S. suicide rate (15.17 per 100,000) was among Whites and the second highest rate (13.37 per 100,000) was among American Indians and Alaska Natives. Much lower and roughly similar rates were found among Asians and Pacific Islanders (6.62 per 100,000), and Black or African Americans (6.03 per 100,000) [1].

History

Demographics are only the initial factor considered in beginning to construct a risk formulation. Other predisposing variables include history of psychological diagnoses, history of suicidal behavior, recent discharge from inpatient psychiatric treatment, and history of abuse.  A review of the literature reveals that the greatest risk of death by suicide is between six months and two years after a suicide attempt [9, 10].

Although after two years following a suicide attempt risk of death by suicide decreases, it is nevertheless important to consider other risk factors. Precipitants or stressors, such as loss (e.g., relationships/interpersonal), identity, financial, divorce/separation, death, loss of employment), acute or chronic health problems, and family difficulties, can function as triggers to a suicidal crisis [7, 11].

Stressors

Recent, acute stressors, have been shown to have greater impact than high levels of chronic stress [12]. In fact, research has demonstrated that the majority of suicide attempters [13] experienced a stressful life event on the day of their attempt. This also supports the importance of a clinician’s detailed assessment of psychosocial stressors in order to understand a patient’s coping abilities.

Severity and hopelessness

In addition to a detailed understanding of psychosocial stressors and coping abilities, a detailed symptom assessment, including assessment of symptom severity, informs a clinician’s understanding of the way in which the diagnosis contributes to and/or exacerbates suicide risk. Feelings of hopelessness are considered “one of the most robust predictors” of future attempts and suicide-related deaths [14, 15].

Psychiatric diagnoses

This is most significantly connected to such disorders as major depressive and bipolar disorders. Though a mental health diagnosis does not have to be present for an individual to make a suicide attempt, a mental health condition does increase suicide risk. Retrospective psychological autopsy studies on completed suicides found that 60 to 90 percent of the suicide cases suffered from psychiatric illnesses prior to death [16].

However, it is just as important to note that less than 1% of those with affective disorders and 4% of those with schizophrenia die by suicide [7]. Psychological diagnoses that demonstrate the highest risk for suicide behavior are mood and anxiety disorders, psychotic disorders, impulse-control disorders, eating disorders, substance use disorders, and personality disorders [17]. Suicide assessment should be conducted with every patient; however, assessment of suicidal ideation and other risk factors in those struggling with the aforementioned diagnoses is particularly prudent.

Though a positive suicide attempt history is widely known as a risk factor for suicide, research also demonstrates that almost half of those who die by suicide complete on their first attempt [18]. The previously identified study demonstrates the significance of an assessment of current/present suicidal ideation and behavior in addition to attempt history. Assessing suicide risk involves understanding the nature of the suicidal thinking. This includes an assessment of the factors of frequency, intensity, and duration of ideation, presence of intent and a plan, availability and lethality of means, and rehearsal or preparatory behavior. History of suicidal experience should also be evaluated as part of the suicide assessment, taking note of the same aforementioned factors, in addition to the context within which the person experienced suicidal ideation/behaviors, and method of coping with the suicide ideations/behaviors.

A Brief Note Regarding Cultural Factors

It is important to highlight the importance of taking culture into account when assessing and treating suicide risk among other cultural groups. Cultural variations to suicide are connected to three factors [19]:

1) Culture affects the types of stressors that lead to suicide.

2) Cultural meanings associated with stressors and suicide affect the development of suicidal tendencies, one’s threshold of tolerance for psychological pain, and subsequent suicidal acts.

3) Culture affects how suicidal thoughts, intent, plans, and attempts are expressed. (p. 1)

Ignoring cultural factors in suicide assessment can contribute to a breakdown in the therapeutic relationship and result in an inaccurate understanding of a patient’s emotional experience. It is therefore imperative for a clinician to engage in appropriate research and questioning to develop an understanding of the impact of a person’s culture on their experience of suicidal thinking.

Putting It All Together

It is helpful to identify the types of questions that are involved in a thorough suicide assessment. In addition to identifying the various areas to assess during the suicide assessment, it is helpful to have an example of the types of questions to ask when engaging in a suicide risk assessment. Regardless of whether patients identify active vs. passive suicidal ideation, it is important that a clinician engage in a thorough assessment of all the factors identified above.

Oftentimes, passive suicidal ideation is considered not as problematic; however, experience and research both demonstrate the importance of thorough assessment and documentation for all individuals who engage in psychological care [22,23]. The questions below have been adapted from research articles cited at the end of this post [5, 6, 21] and are an example of the types of questions a clinician would ask when assessing risk. It is important to engage in all assessments utilizing an empathic lens, just as is done during a psychotherapy session.

Suicide Assessment Questions

Assess for suicide

  • Are you having or have you ever had thoughts of wanting to die or kill yourself
  • What are the thoughts?
    • Ask for the specific thoughts going through their mind related to suicide
    • What are the triggers to these thoughts and how do you manage them?
  • Intensity
    • How intense or overwhelming are the thoughts? (rating scale 1-10)
  • Frequency
    • How often are you thinking about suicide? (Daily? Weekly? Monthly? Number of times per day?)
    • When was the last thought?
  • Duration
    • How long do the thought last? (A few seconds? Minutes? Hours? Longer?)
  • Plan
    • Do you have a plan to kill yourself? How? When? Where?
  • Assess means and access to means
    • Do you have access to weapons (general question with a follow up to asking about the specific means they may have identified in their plan)
  • Intent
    • Do you have any intention of acting on your thoughts? Rate intent (1-10)
    • Have you talked with anyone about your suicidal thoughts?
    • What do you think will happen?
  • Management
    • How do you manage the thoughts? What do you do to cope with them?
  • Rehearsal and/or preparatory behavior?
    • Have you taken any steps in preparation for killing yourself? If so, what steps have you taken?
  • Deterrents to suicide
    • You haven’t acted on these thoughts. What keeps you alive right now? What keeps you going?
    • What are some short- and long-term goals, and/or what are some things you are looking forward to in the short term and long term?

Assess Attempt History

  • Have you ever made a suicide attempt?
  • Gather frequency and details surrounding the attempt
    • How many attempts have you made to date?
    • When was the last attempt?
    • How did you attempt? (Ask about details regarding each attempt)
    • What precipitated each attempt? (What was going on in your life?)
  • Perceived lethality
    • Did you think the attempt would kill you?
    • Did you receive medical and/or psychiatric care?
    • How did you feel about surviving?
  • Help-seeking behaviors
    • How did you get help after the suicide attempt?
    • Who discovered you and what were the circumstances?
    • Did you take any steps to ensure you wouldn’t be discovered? (identify)
  • Preparatory behaviors
    • What prep behaviors, planning, rehearsal behaviors did you engage in?

Assess impulsivity and self-control

  • Subjective self-control
    • Do you consider yourself impulsive? If so, why?
    • How much control do you feel (scale 1-10)
  • Objective control
    • Assess substance use (frequency, magnitude of abuse, duration, access
    • Have you had problems with impulsivity of any kind?

Identify Risk and Protective Factors

  • Risk Factors (not an exhaustive list)
    • Pre-existing/non-modifiable: Age (young and elderly), Gender (males), Race (white), Marital status (divorced, separated, widowed), Family suicide history, abuse/sexual trauma history, Same sex orientation
    • Psychological factors (history of suicide attempt, loss, hopelessness)
    • Stressful life events and chronic stressors
    • History of Psychiatric diagnoses, substance abuse and disorder
    • Medical Conditions, Chronic pain, insomnia, functional limitations
  • Protective factors (not an exhaustive list)
    • Personal characteristics, access to resources, social support system, positive personal traits, access to healthcare, future orientation

Level of Risk and Level of Care

From “Advances in the Assessment of Suicide Risk,” by C.J. Byran and M.D. Rudd, 2006, Journal of Clinical Psychology, 62, p. 198. Copyright 2006 by Wiley Periodicals, Inc. Adapted with permission.
_____________________________________________________________________________________________

When using the above model, it is important to take into account the structure and functioning of your organization and adjust the response as needed. If a patient identifies suicidal ideation, you may consider the use of Brown’s Safety Plan [24] which will require continuous updates to ensure that the coping behaviors identified remain effective.

Additionally, the Collaborative Assessment and Management of Suicidality (CAMS) [25] is a tool that I have used with patients endorsing suicidal ideation and/or behavior as it allows the patient and clinician to develop a greater understanding of what drive a patient’s suicidal thinking. With this information both individuals can work collaboratively to address the drivers over time.

Conclusion

Suicide assessment is a collaborative endeavor. A good clinical interview will feel less like a barrage of questions and more like a conversation in which one person is learning about the other’s experience through listening and well-timed and paced questioning. The goal is always understanding, supporting, and ensuring safety.

Furthermore, an essential component in assessment and treatment is appropriate documentation. It allows for effective communication with other clinicians, consistent tracking of risk level, and allows for a clear understanding of the decision-making process with attention to the reasoning for specific actions.

It is important that factors highlighted in this article are documented and continually monitored to understand individuals’ suicidal experiences and engage with them in treatment that appropriately matches the risk level identified through a clinical integration of the information gathered. Research also demonstrates the added support of suicide assessment scales to assess and monitor suicidal behavior and identify the factors contributing to the suicidal thoughts and behaviors [5, 6, 20]. Culturally informed consistent evidence-based suicide risk assessment can improve the effectiveness of suicide prevention and treatment efforts.

Works Cited

[1] Center for Disease Control (CDC). (2016, July 16). Suicide Statistics . Retrieved from American Foundation for Suicide Prevention: https://afsp.org/about-suicide/suicide-statistics/

[2] Center for Disease Control. (2018, June 7). Vital Signs. Retrieved from CDC: https://www.cdc.gov/vitalsigns/pdf/vs-0618-suicide-H.pdf

[3] O’Connell, P. W., Berman, A., Maris, R. W., & Mosciki, E. K. (1996). Beyond the Tower of Babel: A Nomenclature for Suicidology . Suicide and Life-Threatening Behavior, 237-252.

[4] Maris, R. W. (1992). Assessment and prediction of suicide. New York: Guilford.

[5] Rudd, M.D., Joiner, T., & Rajab, M. H. (2001). Treating Suicidal Behavior: An Effective, Time-Limited Approach. New York: Guilford Press.

[6] Bongar, B., & Sullivan, G. (2013). The Suicidal Patient: Clinical and Legal Standards of Care. Washington DC: American Psychological Association .

[7] Bryan, C. J., & Rudd, M. D. (2006). Advances in the Assessment of Suicidal Risk. Journal of Clinical Psychology , 185-200.

[8] Pisani, A. R., Murrie, D. C., & Silverman, M. M. (2016). Reformulating Suicide Risk Formulation: From Prediction to Prevention. Acad Psychiatry , 623-629.

[9] Christiansen, E. &. (2007). Risk of repetition of suicide attempt, suicide or all deaths after an episode of attempted suicide: A register-based survival analysis. Australian and New Zealand Journal of Psychiatry, 257-265.

[10] Haukka, J. S. (2008). Determinants and outcomes of serious ̈ attempted suicide: A nationwide study in Finland. American Journal of Epidemiology, 1155–1163.

[11] Foster, T. (2011). Adverse life events proximal to adult suicide: A synthesis of findings from psychological autopsy studies. Archives of Suicide Research, 1-15.

[12] Phillips, M. R. (2002). Risk factors for suicide in China: A national case-control psychological autopsy study. Lancet, 1728–1736.

[13] Conner, K. R. (2012). Stressful life events and suicidal behavior in adults with alcohol use disorders: Role of event severity, timing, and type. Drug and Alcohol Dependence. Drug and Alcohol Dependence, 155–161.

[14] Chu, C., Klein, K. M., Buchman-Schmitt, J. M., Hom, M. A., Hagan, C. R., & Joiner, T. E. (2015). Routinized Assessment of Suicidal Risk in Clincal Practice: An Empirally Informed Update. Journal of Clinical Psychology, 1186-1200.

[15] McMillan, D. G. (2007). Can we predict suicide and non-fatal self-harm with the Beck hopelessness scale? A meta-analysis. Psychological Medicine, 769-778.

[16] Law, Y.-w., Wong, P. W., & Yip, P. S. (2010). Suicide with psychiatric diagnosis and without utilization of psychiatric service. BMC Public Health, 431-442.

[17] Chesney, E. G. (2014). Risks of all-cause and suicide mortality in mental disorders: A meta-review. World Psychiatry, 153-160.

[18] Suokas, J. S. (2001). Long-term risk factors for ̈ suicide mortality after attempted suicide–Findings of a 14-year follow-up study. Acta Psychiatrica Scandinavica, 117-121.

[19] Chu, J. P., Goldblum, P., Floyd, R., Bongard, B. (2010). The Cultural Theory and Model of Suicide. Applied and Preventive Psychology, 25-40.

[20] Jobes, D. A. (2016). Managing Suicidal Risk: A Collaborative Approach. New York: Guilford.

[21] Department of Veterans Affairs and Department of Defense (2013, June). VA/DoD

Clinical Practice Guidelines. Retrieved from US Department of Veterans Affairs:

https://www.healthquality.va.gov/guidelines/mh/srb/

[22] Baca-Garcia, E., Perez-Rodrigues, M. M., Oquendo, M.A., Keyes, K.M., Hasin, D. S., Grant, B.

F., & Blanco, C. (2011). Estimating risk for suicide attempt: Are we asking the right

questions? Passive suicidal ideation as a marker for suicidal behavior. Journal of

Affective Disorders, 327-332.

[23] Simon, R. I. (2011). Passive Suicidal Ideation: Still a high risk clinical scenario. Current

Psychiatry, 13(3), 13-15.

[24] Brown, G., Stanley, B. (2011). Safety Planning Intervention: A brief intervention to mitigate

suicide. Cognitive and Behavioral Practices. 19, 256-264

[25] Jobes, D. A. (2016). Managing Suicidal Risk: A Collaborative Approach. New York, NY: The

Guilford Press

Ashwini Lal, PsyD

Ashwini Lal, PsyD

Dr. Lal obtained his undergraduate degree in Psychology and Social Behavior from the University of California, Irvine and a Psy.D. from the Illinois School of Professional Psychology, Chicago. He has trained and worked in different hospitals (County, State, Veterans affairs) and in the university health setting. He has contributed to research literature in the area of social media, has written online articles addressing issues of loss, disappointment, and health behavior change, and has been involved in radio shows with a local physician addressing the etiology and impact of mental health issues on the individual. He currently works in the health center at the California Institute of Technology and prior to this was working at Stanford University. He is passionate about working with those struggling with mood and anxiety disorders, grief/loss, adjustment to various life events/transitions, and sexual and other identity development. He uses an integrative approach to psychotherapy that involves increasing an individual’s awareness into factors contributing to their current struggles and working collaboratively with individuals to increase his/her/their ability to manage current symptoms. He believes this approach reduces immediate symptoms, allowing for a greater focus on gaining in-depth understanding of their struggles, which leads to long-term improvement and increased life satisfaction.
Ashwini Lal, PsyD

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