PIIMIC

Suicide - Risk of Suicide

Understanding and assessing motivation

There are some warning signs, but it is not possible to predict accurately who will or will not attempt to die by suicide. Risk factors include: depression or other mental disorder, psychotic voices urging suicide, previous suicide attempt, lack of concerned support, frequent use of drugs or alcohol, severe stress or recent trauma.

Early warning: severe depression
Many people who contemplate or attempt suicide have suffered long-lasting symptoms of severe depression including sadness, crying, slowdown in actions, lost interest, low motivation, preoccupied feelings of being hopeless, inadequate or guilty (caution: these symptoms may be partly hidden or may mask another underlying mental disorders such as schizophrenia or bipolar). Biological signs of depression include changes in appetite and weight, disturbed digestion, disturbed sleep pattern, low energy, loss of interest or pleasure in life activities. Having thoughts about suicide and making plans are major warning signs.

Ask about it
If a suicide impulse appears to be in the cards, but has not been attempted yet, discussing suicide frankly may help. Don't be afraid to ask, it will not make the subject more likely to proceed: "Have you had any suicidal thoughts recently? Have your thoughts included harming anyone else? Have you attempted suicide before? Do you have definite plans for suicide?" Detailed plans pose the highest risk and urgently need medical attention. (Police can apprehend under sec. 28(1) of the Act for apparent attempts or serious threats of suicide or serious self-harm.)

Medication and risk
A wide range of medications is available to control symptoms of mental disorder. Often they work very well. But in psychiatric disorders, extra caution is needed when meds are restoring energy and insight, because the subject may suddenly gain insight into the extent of his problems, and suffer from the loss of personal hopes and dreams. This can revive suicidal impulses. Symptoms can rebound severely after abruptly going off medication, or medication can fail: the relentless return of symptoms may cause suicidal depression. Any combination of these risk factors may build up to a suicide attempt. Sudden stress or trauma can provide the trigger.

Unexpected or hidden risk
Many people give hints and warnings of deep despair in the weeks or months ahead of a completed suicide. But some give no warning and do not tell others about their thoughts, intentions or plans. The decision to proceed may be hidden; it may be motivated by a combination of rational and psychotic impulses, or it may be purely psychotic: thus, suicide cannot always be predicted or stopped, and survivors should not blame themselves. But warning signs must be taken seriously.

Suicidal risk checklist
Here are a group of factors associated with increased suicidal risk. Even a few of the conditions listed below can be enough to indicate a serious risk in any one case:

1. Demographics - groups, and patterns at risk

• Anniversary of a major loss (or with alcohol dependency, six months after a major loss).
• Family history: Suicides by relatives, attempted or completed.
• Subject's own previous attempts.
• Gender: Women attempt suicide more often. Men complete it more often. Older males more than older women.
• Homeless or moving frequently with reduced opportunities for developing social networks.
• In the elderly, losses of family, friends, independence, health, & connections to society
• In young people, being severely bullied or rejected by peers.
• Lethality: Violent method in previous attempts poses a higher risk than drug overdose, wrist slashing, or manipulative threats of suicide.
• Social Isolation: Single, divorced or widowed people have a higher risk of suicide than married people. Caring for a child decreases risk.
• Unemployed or being unhappily retired and living alone.
• Weapons available: availability of guns or other lethal means (generally applies to males).

2. Stressful conditions

• Chronic physical illness, chronic pain, recent surgery or severe illness of recent onset. Long-term disabling effects of psychiatric illness. Complications with other disorders including drug and alcohol abuse.
• Deterioration and lack of supports. Poorly regulated and unhealthy life style (poor nutrition, lack of exercise and sleep, too much stress). Little or no ongoing guidance, support and care.
• Financial problems: Loss of job, home, money, status, self-esteem, personal security.
• Personal events:  Bereavement or terminal illness of relative or friend. Own divorce, separation, broken relationship, family problems. Own loss of health, real or imaginary.
• Substance abuse:  Increasing use of drugs or alcohol.

3. Emotional and behavioural changes

• Alterations in habits: Either increase or decrease in eating or sleeping.
• Declining interests: Less interest in sex, friends, or activities previously enjoyed.
• Declining performance in school, work, or other activities. Occasionally this can reverse in depression i.e. volunteering for extra duties to preoccupy time and thoughts.
• Defiance, non-compliance:   Elderly people may starve themselves or go off diet; all ages may disobey medical instructions or not take prescribed medication.
• Depression and other mood disorders, anxiety disorders:  Hopelessness, frustration, unbearable pain, loss of coping and compensating resources. Higher risk when unmedicated and/or when coupled with alcohol dependence. Early stages of recovery from depression can be a high-risk period due to increased insight into illness.
• Development of suicidal plan: Acquiring the means, rehearsing, setting a time for the attempt.
• Disturbed by difficult times: Holidays, anniversaries; the first week after discharge from hospital; just before or just after diagnosis of a major illness; just before or during disciplinary proceedings. Saturday nights if subject is not involved in typical weekend social activity.
• Expressing suicidal ideas or feelings. Inappropriately saying goodbye. Ambiguous or indirect hints: "I'm going away on a long trip... Does God punish suicides?...Voices are telling me to do bad things..." Inappropriate joking or writing on morbid themes.
• Hopelessness: It seems that things will never get better and that the pain will continue or get worse.
• Insight into subject's own mental illness during remission, or at onset of unexpected return of symptoms.
• Negative feelings: Worthless, shame, guilt, self-hatred, "no one cares," afraid of losing control or of harming self or others.
• Neglect of personal welfare and grooming. Deteriorating physical appearance.
• Overwhelming pain: Pain that threatens to swamp the subject's coping abilities; often arises from long-standing problems/burdens made worse by recent event(s) - the "last straw" - either new pain or new loss of coping resources.
• Personality changes: Personality becomes sad, withdrawn, flat, tired, apathetic, anxious, irritable, prone to angry outbursts.
• Powerless: Subject has exhausted available resources for compensating and reducing pain.
• Reckless behaviour: High risk physical activity, unexplained serious accidents, drug overdose.
• Self-inflicted injuries: Deliberate cuts, burns, head-banging.
• Settling affairs: Making out a will, giving away favorite possessions.
• Unexplained improvement in clinical symptoms, suddenly calmer and happier for no obvious reason (this can result from deciding on a definite suicide plan).

Adolescent Depression
Signs and symptoms of adolescent depression, according to clinical training developed by Canadian psychologist Heather Fiske for the BC Ministry for Children and Families in partnership with Mheccu, UBC.

Physical

• Sleep disturbance
• Change in appetite, eating
• Lack of energy, fatigue
• Loss of sexual desire
• Digestive problems
• Pain

Emotional

• Sadness
• Shame, worthlessness
• Irrational guilt
• Irritability, resentment
• Anhedonia (numb, no joy in life)
• Helplessness/hopelessness
• Pain

Cognitive

• Concentration difficulties
• Memory problems
• Indecisiveness
• Suicidal ideas
• Lack of interest
• Pessimism

Behavioural

• Withdrawn from social activity
• Crying spells - or flat response
• Slowing of activity - or restless
• Neglecting responsibilities
• Neglecting personal care
• Reduced coping ability
• Complaints
• Substance abuse.