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Suicidal Thoughts (cont.)

Methods of Suicide

In general, men are more likely to use guns, knives, or other violent means. Women are somewhat more likely to take an overdose or some other form of poisoning. This gender difference in methods likely accounts for the higher suicide completion rate in males. Globally, limited data is available about suicide methods. The most common means in different countries are often related to what is accessible and are sometimes based on regional trends. The most extensive data on methods is from the U.S. Centers for Disease Control and Prevention (CDC) National Violent Death Reporting System.

By far, firearms are the most common method of suicide death. Over half of U.S. suicide deaths are from a self-inflicted gunshot wound. Firearms accounted for 57% of suicide deaths in men and 33% in women. It is estimated that 90% of suicide attempts with a firearm are lethal. More U.S. gun deaths are a result of suicide than homicide (in 2009, 19,000 vs. 11,500). Areas where gun ownership is higher tend to have more gun suicides. Globally, high-income countries other than the U.S. have much lower gun ownership, and suicide with firearms accounts for only 4.5% of all suicide deaths.

Deaths by hanging and suffocation (25.6%) and poisoning (including prescription drugs, street drugs, poisons, and carbon monoxide; 16.3%) are the next most common methods. Poisoning is the most common method of suicide in women, accounting for 36.5% of deaths. These three categories account for over 90% of U.S. suicide deaths in both men and women. Other less common methods include falls/jumping, motor vehicles, and cutting/stabbing.

In other countries, other means are more common. In many low-income countries with a high percentage of rural citizens, self-poisoning with pesticides is a suicide method and is thought to account for around 30% of all suicide deaths globally. Because of easy access to means, hanging is also a common method in low-income countries. In Hong Kong and China, where much of the population lives in high-rise apartments, jumping off of high buildings is a common suicide method. Use of charcoal fires for carbon monoxide poisoning has spread as a common means in China, Hong Kong, and other Asian countries over the past decade.

Warning Signs Before a Suicide Attempt

Many people show warning signs or changes in behavior prior to a suicide attempt. While no specific behavior, or pattern of actions, can predict a suicide attempt, it is important to watch for signs and behaviors that are concerning. These warning signs parallel the risk factors described above. Changes or increases in these behaviors are particularly concerning:

  • Increased use of drugs or alcohol
  • Statements threatening to hurt or kill oneself
  • Talking or writing about death or suicide
  • Looking for access to firearms, pills, or other means for committing suicide
  • Statements of hopelessness, purposelessness, helplessness/feeling trapped
  • Increased anger or rage, threats of revenge
  • Increased risky or reckless behavior
  • Preparing a will or insurance policies; giving away important personal belongings; making arrangements for belongings, pets, etc., to be cared for.
  • After a long period of depression and low energy, suddenly seems brighter or full of energy

Any of these may be concerning, but they are particularly troubling when they are paired with recent losses, including deaths, breakups, job or financial losses, or medical diagnoses. If you see these warning signs, it is critical to talk to the person openly about any concerns and get them connected to help.

Evaluating Suicide Risk

One of the most important, but also most difficult, tasks that mental-health professionals do on a regular basis is the suicide risk assessment. Because suicide is relatively uncommon, even in those with mental-illness diagnoses, predicting who may attempt suicide, and when, is remarkably difficult. We know from research, however, that most people who commit suicide will see a doctor or mental-health professional within the month before they end their lives. Knowing this, we must continue to work to be better at identifying those at risk.

Some professionals approach the suicide assessment by using structured interviews or rating scales to assess risk. Dr. Aaron Beck developed one of the earlier tools, the Scale of Suicidal Ideation (SSI). The SADPERSONS scale was easy to use and had fairly widespread acceptance. However, recent research showed that the SADPERSONS scale was not an accurate assessment for risk. More recently, the Columbia Suicide Severity Rating Scale (C-SSRS) has been used in a variety of settings. Validated rating scales have the advantage of being tested on many subjects and of providing an objective, often numeric score to use in making decisions. However, because suicide is a complex and low-frequency event, no scale can be completely accurate. Clinicians must still rely on good clinical judgment and account for factors not assessed in these scales.

A broader approach, integrating a detailed clinical history along with a structured interview, provides a better basis for decisions about risk. However, pressures for clinicians to see patients more quickly can limit how practical this can be. One example of an interview-based approach which can be adapted to different clinical situations is the Chronological Assessment of Suicide Events (the CASE approach). The goal of this approach is to get a detailed account of suicidal thoughts, preparations and attempts, along with current psychiatric symptoms to best make treatment recommendations.

For primary-care doctors, time is even more limited and must also be used to address a range of other medical issues. Screening every patient for suicide risk is impractical and has been shown to have limited value in preventing possible suicides. Current recommendations are to screen primary-care patients for depression and anxiety, and by providing appropriate treatment, suicide risk may be reduced.

Medically Reviewed by a Doctor on 11/18/2014
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