In this study, about 70% of patients who completed suicide had recently sought treatment. Will you recognize those at risk?
Which patients are at greatest risk for suicide? To answer this question, Shareh O. Ghani, MD, and colleagues set out to identify characteristics of recent completed suicides among a Medicaid population in Maricopa County, Arizona. They studied 100 consecutive cases ruled suicides after autopsy.1 Dr Ghani presented their data at APA 2016.
According to the World Health Organization (WHO), suicide accounts for 800,000 deaths worldwide each year.2 It is the 2nd leading cause of death among young people age 15 to 29. The highest rates of suicide are in those over age 70. About 90% of those who complete suicide have a psychiatric diagnosis; mood disorders are the most common.
The regions of highest risk are East Africa and Eastern Europe. Women are twice as likely as men to be depressed, but men are 3 times more likely than women to complete suicide.
Suicide rates by diagnosis are somewhat imprecise. The WHO reports 2% to 15% of patients with MDD die by suicide, 3% to 20% of those with bipolar disorder, and 6% to 15% of those with schizophrenia.
Suicide is the leading cause of premature death in patients with schizophrenia (75% to 95% of those who complete suicide are male). Common risk factors include hopelessness, recent hospital discharge, family history of suicide, and past attempts.
Younger women appear to be using more lethal means of suicide than previously thought.
In the recent study by Dr Ghani and colleagues,1 59 males and 41 females completed suicide. The highest rates were seen in the middle-aged group. The diagnosis most associated with completion was bipolar disorder (54% of all cases). MDD accounted for another 10%, schizophrenia/schizoaffective disorder 17%, and anxiety disorders 4%.
Common stressors that occurred within 30 days of suicide included change in living situation (16%), change in care (14%), family loss (14%), substance abuse (14%), recent hospitalization (7%), and change in relationship (10%). Visits to psychiatric emergency departments and/or hospital admissions were noted in 72% of females and 38% of males, which reinforces the notion that female patients may be more help-seeking.
About 70% were seen by a primary care or mental health provider within 30 days of suicide. Other estimates are as high as 83% for health care contacts, which underscores the need to identify individuals at high risk.
Among those already receiving mental health treatment, males were 43% and 33% non-adherent among middle-aged and younger-age groups, respectively. The non-adherence rate for females was 55% in both age groups. By diagnosis, adherence was 70% for those with MDD, 40.7% for bipolar disorder, and 41.2% for schizophrenia.
Among completers, 80% were deemed to have family support, although only 19% allowed family to participate in treatment planning. Leading up to completion, 62.5% of patients had meaningful contact outside the home and a surprising 78% were contacted by case management (although this percentage may be lower in non-Medicaid populations).
The most common methods of suicide were overdose (35.7%), firearms (33.7%), and hanging (25.7%). Both young males and young females were more likely to use firearms than their middle-aged counterparts.
The highest rates of suicide are in those over age 70.
Based on the study results, Dr Ghani emphasized the following points:
• There is a considerable amount of help-seeking in the days leading up to a completed suicide
• Bipolar disorder is the highest risk diagnostic category across all demographics
• Younger women appear to be using more lethal means of suicide (ie, hanging and firearms) than previously thought
Data are preliminary and must be interpreted with caution. The authors acknowledge limitations, including single study location, Medicaid patients only, and a small sample size. In light of the increased suicide rate reported by the CDC, clinicians must be all the more cognizant of factors that increase a patient’s risk.
Dr Williams is Assistant Professor of Psychiatry and Health Behavior and Medical Director of the Inpatient Service at the Medical College of Georgia, Georgia Regents University, in Augusta, Georgia.
1. Ghani S. A retrospective review of 100 suicides in Phoenix, Arizona 2009. Paper presented at: American Public Health Association Annual Meeting; October 31-November 04, 2015; Chicago, IL. Abstract 338683.
2. World Health Organization. Preventing Suicide: A Global Imperative. 2014. http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/. Accessed May 17, 2016.