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Understanding the risk factors for suicide

People who attempt suicide often pose particular challenges to all levels of the healthcare profession. Subsequently they are dealt with cautiously or avoided, which, due to the very nature of their difficulties, may increase their vulnerability. Rhian Brown and Scott Kane explain …

Rhian Brown
RMN BA Nursing CBT Dip
Liaison Psychiatry Nurse

Scott Kane
RMN CBT MSc
Nurse Consultant Liaison Psychiatry
Primary Care Division
NHS Tayside

Suicidal behaviour is a major public health concern worldwide. Approximately one million people lose their lives as a result of suicide each year, which equates to one suicide every 40 seconds.(1) Due to soaring figures of suicide in the UK, with approximately 5,000 people per year in England alone, the government has set a target to reduce suicides by at least one-fifth by 2010.(2,3) As a direct result, the National Strategy for Suicide Prevention in England was launched in 2002 to explore ways of reducing suicide rates. Recent figures suggest that progress has been made; the Health of our Nation Baseline rate was 9.(2) deaths per 100,000 people between 1995 and 1997. Further figures identified following a review of the effectiveness of the National Strategy for Suicide Prevention in England indicate a reduction to 8.5 deaths per 100,000 people between 2003 and 2005.(2)
In Scotland the Scottish Executive invested money in the Choose Life Initiative, a national strategy exploring ways of reducing the national rate of suicide between 2002 and 2013 by 20%.(4) The strategy was independently evaluated in 2006 and suggests good progress: a reduction of 12% in suicide rates between 2000 and 2005.(5)
While significant positive progress has been made, healthcare professionals must not become complacent in their approach to this vulnerable group of individuals. It should also be recognised that the initial response by healthcare professionals to those who have attempted suicide or expressed suicidal ideation, could have a significant impact on the individual and the outcome of any intervention.
People who have attempted suicide or are contemplating doing so are likely to be sensitive to professionals' attitudes and behaviours towards them. Surviving a suicide attempt may be perceived as another failure. This may then reinforce the individual's feelings of hopelessness and worthlessness, which can subsequently increase their risk of further suicide attempts. It is therefore paramount that they receive a kind, respectful and nonjudgmental response from healthcare professionals.6
Building a therapeutic relationship is vital. Whether the contact is minimal or more indepth, the intervention can have a significant impact. The building of a therapeutic relationship is highly dependent on how an individual is approached, and effective interpersonal communication skills are therefore critical. Rogers suggests that the fundamental principles of the development of a relationship are acceptance, empathy and positive regard.(7) This will increase the likelihood of the development of a genuine, open and respectful relationship leading to positive engagement from both the client and the professional.
A further important factor associated with communication relates to asking directly if the client has been experiencing thoughts of a suicidal nature. While some practitioners may understandably be uncomfortable asking this question, it is nevertheless something that they must learn to adapt to. Reassuringly, there is no evidence to suggest that openly asking about suicide will "plant the seed". By avoiding asking such questions, practitioners may inadvertently be conveying a lack of understanding regarding the patient's emotional and/or psychological difficulties. Equally, they may be conveying that talking about suicide is strictly taboo.

Understanding suicide risk
The risk factors associated with suicide are so wide and varied that it can be extremely difficult to determine who exactly is at risk. The main reason for this relates to the fact that the risk factors can apply to a much wider group than those who are actually at risk of suicide.
Simply carrying out a "ticklist" of risk factors related to suicide is both unwise and inadequate. Nevertheless, it is still important to have a good awareness of the potential risk factors, the detection of which should be incorporated into a comprehensive biopsychosocial assessment.
Suicide risk can never be eliminated; however, we can robustly assess and manage risk and prevent some suicides from taking place. Unfortunately we can never tell for certain if a suicide has been prevented, as this is notoriously difficult to audit. Despite the widespread view that individual deaths are inevitable, this should not prevent us from taking steps to improve safety.(8) A good knowledge and understanding of the risk factors for suicide (in conjunction with the skills to carry out a biopsychosocial assessment) can help healthcare professionals make an informed clinical decision and ultimately provide the patient with relevant care and treatment in an attempt to minimise suicide risk.
Common risk factors for suicide generally fall into the following four categories:

  • Individual mental ill health/medical factors.
  • Psychological factors.
  • Biological factors.
  • Social factors.

Individual mental health/medical risk factors
While these risk factors are some of the most common associated with suicide, it is important to clarify that this list is by no means exhaustive.

Previous history of self-harm
Self-harm is one of the most important factors that needs to be taken into consideration when assessing suicide risk. In an extensive study carried out by Hawton, a very strong relationship between self-harm and suicide was identified (between 40% and 60% have a history of at least one episode of self-harm).9 Unfortunately, attitudes towards individuals who self-harm can sometimes be negative with some labelled as attention seekers, time wasters and malingerers. These terms are extremely unhelpful and can lead to patients being alienated and, paradoxically, reinforce any negative attributes that they may already possess. Ignoring this particular patient group is both foolhardy and potentially very dangerous.

Harmful substance misuse
The five-year report of the National Confidential Inquiry into Suicide and Homicide suggests that of all inquiry cases, 44% had a history of harmful alcohol misuse, with a further 30% having a history of harmful drug misuse.8 The use of alcohol also plays quite a significant role in the events before and during episodes of self-harm and attempted suicide. It was also reported that 27% of those who died had a dual diagnosis of severe mental illness and substance dependence/misuse. This is clearly another patient group that healthcare professionals would be wise to pay closer attention to.

Mood disorder
There is clear evidence that links the signs and symptoms of depression (eg, hopelessness, guilt, anhedonia [inability to experience any pleasure or joy], insomnia and diminished concentration) with suicide. Particular emphasis on identification of the symptomatology of depression is therefore highly significant when assessing and managing suicide risk.(10)

Personality disorder
Personality disorders (PDs) are common in the general population, with prevalence rates of up to 13.4%.(11,12)
Following psychological autopsy of people who commit suicide, several studies have shown that 34% have had a primary diagnosis of PD.(13)

Schizophrenia
Psychiatric literature generally quotes a lifetime schizophrenia suicide prevalence of 10%. However, a more recent study estimates that the true rate is 4.9%, with the majority of those committing suicide around the time of illness onset.(14)

Psychological factors
It would appear that one of the most concerning psychological risk factors associated with suicide relates to levels of hopelessness. In a study by Beck et al it was concluded that individuals who scored high on the Hopelessness Scale had very high rates of suicide within the following five to 10 years.(15)
Further psychological risk factors include poor problem solving skills, dichotomous thinking (a tendency to only see extremes such as good or bad, black or white, all or nothing) and impulsivity.(16)

Biological factors
Several studies have suggested a relationship between suicide and biological factors, with some studies suggesting the possibility of a genetically inherited risk factor for suicide that is independent of the inheritance of psychiatric diagnosis.(16) Basically, relatives of individuals who commit suicide are at higher risk of committing suicide themselves.

Social factors
There are a wide range of social factors that can contribute to the risk of suicide and it would seem that the time preceding suicide is usually characterised by a culmination of life events and stressors. Most commonly, these events tend to relate to issues such as unemployment, marital breakdown (which has been associated with over 60% of suicide attempts in the US), family/relationship difficulties, financial problems, somatic illness, work-related stress and recent loss.(17, 18)

Summary
Over the past 20 years suicide has become a major concern for public health services. National strategies have been put into place to help address what was an alarming trend. These strategies appear to be having a positive impact; however, it is of paramount importance that we do not become complacent simply because of the positive results. As healthcare professionals we all have a duty and responsibility to maintain and carry forward the good work that has already been done.
Some healthcare professionals may find that working with individuals who are at risk of suicide can be somewhat daunting and anxiety provoking due to their own perceived lack of knowledge or experience. It would seem that the main skills requirements centre around a good knowledge base regarding the various risk factors associated with suicide along with the ability to know what to do in a crisis and to prevent problems developing or becoming worse (see Box 1).
If you suspect that someone may be at risk of suicide - ask!

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References

  1. 1. World Health Organization. World Health Report 2000. Health systems: improving performance. Geneva: WHO; 2000.
  2. Department of Health. National suicide prevention strategy for England. London: DH; 2002. 
  3. Department of Health. Saving lives: our healthier nation. London: DH; 1999.
  4. Scottish Executive. Choose life. Making it work together. A national strategy and action plan to prevent suicide in Scotland. Edinburgh: Scottish Government; 2002.
  5. Scottish Executive. Evaluation of the first phase of choose life: the national strategy and action plan to prevent suicide in scotland. Scottish Government; 2006.
  6. Wiklander M, Samuelsson M, Asberg M. Shame reactions after suicide attempt. Scand J Caring Sci 2003;17:293-300.
  7. Rogers CR. Client centred therapy. In: Ariento S, editor: American handbook of psychiatry. New York: Basic Books; 1966.
  8. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Avoidable deaths. Manchester: Manchester University; 2006.
  9. Hawton K. What happens to deliberate self-harm ("attempted suicide") patients in the long term? Oxford University; Centre for Suicide Research; 2005.
  10. Zoltán R. Suicide risk in mood disorders. Curr Opin Psychiatry 2007;20:17-22. 
  11. Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in a community sample. Arch Gen Psychiatry 2001;58:590-6.
  12. Cheng AT, Mann AH, Chan KA. Personality disorder and suicide. A case-control study. Br J Psychiatry 1997;170:441-6.
  13. Black DW, Blum N, Pfohl B, Hale N. Suicidal behaviour in borderline personality disorder: prevalence, risk factors, prediction and prevention. J Personal Disord 2004;18:226-39.
  14. Palmer AB, Pankratz SV, Bostwick JM. The lifetime risk of suicide in schizophrenia. A reexamination. Arch Gen Psychiatry 2005;62:247-53.
  15. Beck AT, Steer RA, Kovacs M, Garrison B. Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry 1985;142:559-63.
  16. Gelder MG, Harrison P, Cowen P. Oxford textbook of psychiatry. 5th ed. Oxford: Oxford University Press; 2006.
  17. Collier J, Longmore M, Brinsden M. Oxford handbook of clinical specialties. 7th ed. Oxford: Oxford University Press; 2006.
  18. Gelder MG, Lopez-Ibor JJ, Andreasen N. Oxford textbook of psychiatry. Oxford: Oxford University Press; 2000.