Recognizing Suicide Risk Factors in Primary and Psychiatric Care

Larry Culpepper, MD, MPH


October 25, 2010

In This Article

Risk Factors: What to Look Out For

An understanding of the risk factors for suicide can facilitate the recognition of high risk patients, and help in their assessment. Patient characteristics that increase suicide risk include:

Past attempts: Half of suicide completers attempted suicide previously and 1 out of 100 suicide attempt survivors die by suicide within the next year, a risk 100-fold greater than that in the general population.[6]

Psychiatric: Patients with multiple psychiatric conditions appear to be at higher risk than those with uncomplicated depression or an anxiety disorder.[7] Psychiatric disorders most frequently associated with suicide include depression, bipolar disorder, alcoholism or other substance abuse, schizophrenia, personality disorders, anxiety disorders (including panic disorder), posttraumatic stress disorders, and delirium.[8,9] Anxiety disorders double risk for suicide attempt (odds ratio = 2.2)[10] but a combination of depression and anxiety greatly increases the risk (odds ratio = 17).[9] In depressed patients, comorbid personality disorder also correlates strongly with suicide attempts. In addition, 20% to 25% of suicide completers are intoxicated at the time.[3]

Age, sex, and race: Although young adults attempt suicide more often than older adults, the risk for completed suicide increases with age.[11] Men are 3 times more likely to complete suicide, although women attempt suicide 4 times more often than men.[12] These differences are the result of the lethality of the chosen method (eg, firearms) more than to a difference across age or sex in completion rates for a particular method.[13] White people complete about 90% of suicides in the United States; 72% are by white men.

Work status: Unemployed and unskilled individuals are at increased risk compared to those employed and skilled; occupational failure may lead to higher risk. Physicians, particularly female physicians, may be at increased risk; a 25-study meta-analysis yielded a suicide rate ratio for female physicians of 2.3 and for male physicians of 1.4 compared with the general population.[14]

Impulsivity: Impulsivity increases the likelihood of acting on suicidal thoughts, and the combination of hopelessness, impulsivity, and substance abuse-related disinhibition may be particularly lethal.[3] This combination occurs most frequently in young adults.

Health: Medical illness, including chronic pain, chronic disease, and recent surgery increases suicide risk.[3]HIV infection by itself does not increase risk.[15]

Family factors: Having a first-degree relative who committed suicide increases risk sixfold. The heritability of suicide is in the 30% to 50% range, although it is uncertain whether genetic makeup contributes to the underlying psychiatric disorder or to the suicide itself.[3] Individuals who have never married are at the highest risk for completed suicide, followed in descending order by those who are widowed, separated, or divorced; married without children; and married with children. Risk also increases in patients who live alone, who have lost a loved one, or who have experienced a failed relationship within one year.[16] The anniversary of a significant loss is also a time of increased risk. Having a spouse who committed suicide increases the risk for suicide in the survivor.[17]

Abuse and other adverse childhood experiences increase the risk for suicide in adults, at least partially mediated by the presence of alcoholism, depression, and illicit drug use, which also are strongly associated with adverse events in childhood.[3]

Access to means: Of all suicides in the United States, 57% -- and 62% in men -- are caused by a firearm, with rates increased 4- to 10-fold in adolescents who live in a household with a gun.[18] The second leading methods of suicide in the United States are hanging for men and poisoning for women.

Hopelessness: Hopelessness is a concept that may contribute to suicide, independent of depression. One multivariate analysis found hopelessness to be 1.3 times more important than depression in explaining suicidal ideation.[19] It may mediate the relationships between interpersonal losses, loneliness, low self-esteem, and suicide. Those in whom hopelessness persists when depression has remitted continue to be at high risk for suicide.[3]

Protective factors: Family connectedness and social support are protective. Family discord increases the risk for suicide.[3] Parenthood, particularly for mothers, and pregnancy decrease the risk for suicide.[20] Participating in religious activities and religiosity are associated with a lower risk for suicide.

Knowledge of the above risks and protective factors can be used in assessing patients for whom suicide risk is a concern.


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