CRACKCast E115 – Suicide

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This episode of CRACKCast covers Rosen’s Chapter 115, Suicide (Chapter 105, 9th Edition). This is the last chapter in the psychiatric section of Rosen’s. Dealing with patients with suicidal ideations, or who have attempted to commit suicide can be difficult, especially in terms of risk stratifying patients to determine whether they are safe to go home, or need admission for further psychiatric assessment. This chapter will cover risk factors, protective factors, and assessment of the suicidal patient.

Shownotes – PDF Here


Key Concepts

  • Suicide is a common—but preventable—cause of death.
  • Suicidal thoughts or behaviors are often triggered by a treatable or reversible short-term crisis, and most attempt survivors are grateful to be alive.
  • Suicide risk changes over time, and estimation of imminent risk is not evidence based at this time.
  • Routine “screening” labs provide little value for most ED patients with self-harm behaviors. Evaluation should be directed at specific concerning signs or symptoms.
  • Many suicidal individuals see a physician shortly before their death.
  • An ED visit for suicidal thoughts or behaviors represents a crisis and a teachable moment.
  • An empathetic, patient-centered, collaborative approach that incorporates information from collateral sources (eg. family) can optimize care.
  • Suicide precautions in the ED include appropriate use of “sitters” and, when necessary, physical and chemical restraints and involuntary commitment.
  • Brief risk assessment by the emergency clinician can identify patients in need of a comprehensive evaluation and consultation with a mental health specialist (if available).
  • Patients at low risk of suicide may be discharged home to a safe and supportive environment without access to guns or toxic medications.
  • Discharged patients should receive education and safety planning in the ED and should have early mental health follow-up appointment.

Rosen’s in Perspective

More than 1 million people die worldwide every year from suicide!!! Commonly, we associate suicide with psychiatric disorders, such as:

  • Depression
  • Bipolar disorder
  • Alcoholism or other substance abuse
  • Schizophrenia
  • Personality disorders
  • Anxiety disorders (including panic disorder, post-traumatic stress disorders, and delirium)

High risk factors for suicide  =

  • Anxiety disorders – double the risk of suicide attempts
  • Combination of depression and anxiety greatly increases the risk, odds ratio = 17!!!!
  • Symptoms of psychosis (delusions, command auditory hallucinations, paranoia)
  • ETOH abuse – 2 to 18% suicide rate of alcoholics.
    • 90% men.
    • 20 to 25 % are intoxicated
    • 30% of all suicides have ETOH in their system

A few terms to know about and use:

  • Suicidal Ideation refers to thoughts of causing one’s own death, with or without a specific plan.
  • Suicidal Behavior is any behavior with the intent to end one’s life.
  • A Suicide Attempt is a “non-fatal self directed potentially injurious behavior with any intent to die as a result of the behavior.
  • An Interrupted Suicide attempt is a suicide attempt aborted by the individual or another person.
  • Occult Suicide is suicidal thoughts or behaviors not admitted to by the patient, such as self-destructive acts disguised as accidents (eg. an intoxicated, depressed driver who crashes his car).
  • Suicide by Cop is when a suicidal individual intentionally provokes a police officer by orchestrating a situation in which the officer is forced to shoot in self-defense or to protect other civilians.

[1] Name 10 risk factors for suicide

Look for that Acute Crisis – What’s tipping you over to consider suicide NOW

Table 105.1 (9th Edition) – Risk Factors for Suicide

Demographic·      Age groups: Adolescence, older age

·      Gender: Male

·      Ethnicity: White, American Indian, or Alaskan Native

Biopsychosocial·      Mental disorders (including mood disorders, schizophrenia, borderline personality disorder, anxiety disorders, post-traumatic stress disorder)

·      Alcohol or substance abuse

·      Prior suicide attempt

·      Recent psychiatric hospital discharge

·      Family history of suicide

·      History of trauma or abuse

·      Chronic pain or major physical illness

·      Terminal illness

·      Hopelessness

·      Impulsive and/or tendencies

Environmental·      Job or financial loss (eg, unemployed, homeless)

·      Relational or social loss (eg, widowed, bereaved, recent incarceration)

·      Access to lethal means (eg, guns)

·      Local suicide clusters with a contagious influence

Sociocultural·      Lack of social support and sense of isolation

·      Stigma associated with help-seeking behavior

·      Inadequate access to care for mental health or substance abuse

·      Certain cultural and religious beliefs (eg, suicide as a noble resolution of a personal dilemma)

·      Exposure to, including through the media, and influence of others who have died by suicide

According to UpToDate, risk factors include:

  • Psychiatric disorders
  • Hopelessness and impulsivity
  • History of previous suicide attempts or threats
    • Because 10% to 15 % of suicide attempters will ultimately die by suicide, prior suicide attempt is one of the most important predictors of a future attempt. At the same time, up to 80% of suicide completers have no prior history of attempts and die on the first known attempt.
  • Age, sex, and race
  • Marital status
  • Occupation
  • Military service
  • Health
  • Adverse childhood experiences
  • Family history and genetics
  • Antidepressants
  • Other (accessibility to weapons/firearms, live alone, have lost a loved one, or have experienced a failed relationship within one year, the anniversary of a significant relationship loss is also a time of increased risk)

[2] Name an additional 5 risk factors for adolescent suicide

Table 105.2 (9th Edition) – Additional Risk Factors for Suicide in Adolescence

Demographic·      Sexual orientation (lesbian, gay, bisexual, unsure)
Biopsychosocial·      Sedentary activities (≥3 hours day TV or video games; sleep <8 hours per night)

·      Weight concerns (perceive self as overweight; prior fasting, diet pills, or vomiting/laxatives for weight control)

·      Sexual health (prior sexual intercourse; sex before age 13; four or more partners; sexually active; no use of condoms)

Environmental·      Exposure to violence (carried a weapon, in a physical fight, bullied electronically or in person, forced to have sex, hit by significant other, felt unsafe or threatened at school)
Sociocultural·      Participation in Goth subculture

[3] Describe the SAD PERSONS Scale

One point for each “yes” answer:

S: Male sex
A: Age (<19 or >45 years)
D: Depression
P: Previous attempt
E: Excess alcohol or substance use
R: Rational thinking loss
S: Social supports lacking
O: Organized plan
N: No spouse
S: Sickness

This score is then mapped onto a risk assessment scale as follows: 0–4: Low, 5–6: Medium, 7–10: High

*** Although the original study in 1996 found this to be a SPECIFIC tool, it is not SENSITIVE enough to be clinically useful. In short, it’s useless***

[4] Describe 4 potential targeted investigations for patients presenting to the ED with suicide

 Emergency clinicians are often asked to provide medical clearance of patients with psychiatric emergencies. However, the preferred term is focused medical assessment; a negative focused medical assessment does not indicate an absence of medical problems but rather that such problems can be addressed on a non-urgent basis. A focused medical assessment should be accomplished primarily through obtaining an adequate patient history and physical examination.

The examination should assess for evidence of:

  • Drug ingestion
  • Trauma or associated medical illness
  • Evidence of self-harm behavior such as wrist-cutting
  • Cognitive status
  • Vital signs, pupils, skin, and nervous system examinations are helpful in detecting organic conditions, particularly toxidromes associated with common ingestions (see Chapter 139).
  • In the case of altered mental status, the provider should determine whether the condition is caused by an organic (medical) or functional (psychiatric) cause.

But here are some targeted diagnostic tests, which may be ordered based on your history and physical.

 Table 105.3 (9th Edition) – Potential Targeted Diagnostic Testing in ED Patients Presenting with Suicidality

General Labs·      Pregnancy test (in females of childbearing age)

·      Complete blood count (for suspected anemia)

·      Serum chemistries (for suspected electrolyte abnormalities)

·      Urinalysis (for suspected infection)

·      Liver function tests (LFTs), ammonia (for suspected liver disease or valproic acid use)

·      Coagulation studies

·      Thyroid-stimulating hormone (TSH) (for suspected thyrotoxicosis or thyroid abnormality)

Toxicologic Labs·      Urine screen for drugs of abuse (to explain acutely altered mental status; to assist ongoing psychiatric care)

·      Ethanol level (to explain acutely altered mental status; to assist ongoing psychiatric care)

·      Testing for potential toxic ingestion (eg, aspirin, acetaminophen, serum osmolar gap)

·      Serum levels of measurable drugs (eg, lithium, valproic acid, phenytoin)

Imaging·      Electrocardiogram (EKG) (in patients with cardiac history or on medications known to affect cardiac conduction)

·      Chest x-ray

·      Computed tomography (CT) scan of head (to explain acutely altered mental status)

[5] Name 3 protective factors against suicide

  • Social support & family connectedness
  • Pregnancy
  • Parenthood (particularly for mothers)
  • Religiosity and participating in religious activities

Put in another way, these are the low risk patients:

  • Denial of suicidal thoughts, plan, intent
    • No or mild sadness or anger; no psychosis
    • No or 1 recent attempt with low lethality
    • No or limited substance use
    • Good support, accepting of help, hopeful for future

As we wrap this up…a quick discussion about suicide inquiry:


This post was copyedited and uploaded by Andrew Guy.

Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine (Innovative Sport Medicine Calgary). His interests are in paediatrics, endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.