2. Introduction Suicide is a complex human behavior. There is no one reason why an individual chooses to end his or her life. Suicide has been defined as an act with a fatal outcome that is deliberately initiated and performed by the person in the knowledge and expectation of its fatal out come Epidemiology Attempted : Completed = 20:1 M:F =3:1 for completed; 1:4 for attempts Risk Factors: Epidemiologic Factors:  age: increases after age 14, second most common cause of death for ages 15-24; higher rates in persons> 65yrs

3.  sex: male  race/ethnic background: white or native Canadians on reserves  marital status: widowed/ divorced  living situation: alone, on children < 18 yrs old in the household  other: stressful life events; access to firearms psychiatric disorders  mood disorders (15% lifetime risk in depression; higher in bipolar)  Anxiety disorders (especially panic disorder)  Schizophrenia (10-15% risk)  Eating disorders (5% lifetime risk)

4.  Adjustment disorders  Conduct disorders  Personality disorders Past history  Prior suicide attempt  Family history of suicide attempt/completion Clinical Presentation Symptoms associated with suicide:  Hopelessness‘  Anhedonia  Insomnia  Severe anxiety  Impaired concentration  Psychomotor agitation  Panic attacks

5. Approach Every patient: “Have you had any thoughts of wanting to hurt/kill yourself?”  Ideation- “Do you have thoughts about ending your life, committing suicide?”  Passive- “Would rather not be alive but has no active plan for suicide?”  e.g. “I’d rather not wake up.” “I would not mind if a car hit me”  Active  e.g. “I think about killing myself”  Plan: “Do you have a plan as to how you would end your life?”

6.  Intent- “You talk about wanting to die, but are you planning to do this?” “What has stopped you from ending your life?”

7.  Past attempts- Highest risk if previous attempt in past year  Ask about lethality, outcome, medical intervention Assessment of Suicidal Ideation onset and frequency of thoughts- “When did this start? How often do you have these thoughts?” control over suicidal ideation- “Can you stop the thoughts or call someone for help?” lethality- “Do you want to end your life? Or get a ‘release’ from your emotional pain?” access to means- “How will you get a gun?” “Which bridge do you think you would go to?” time and place- “Have you picked a date and place? Is it an isolated location?”

8. provocative factors- “What keeps you alive (e.g. friends, family, pets, faith, therapist)?” final arrangements- “Have you written a suicide note? Made a will? Given away your belongings?” practiced suicide or aborted attempts- “Have you put the gun to your head? Held the medications in your head? Stood at the bridge?” ambivalence- “There must be a part of you that wants to live….you came here for help” Assessment of Suicide Attempt setting- isolated vs. others present, chance of discovery planned vs. impulsive attempt, triggers/stressors intoxication medical attention- brought in by another person vs. brought in by self or ER

9. time lag from suicide attempt or ER arrival expectation of lethality, dying reaction to survival- guilt/ remorse vs. disappointment// self-blame Management higher risk  patients with a plan, access to lethal means, recent social stressors, and symptoms suggestive of a psychiatric disorder should be hospitalized immediately  donot leave patient alone, remove potentially dangerous objects from room  if patient refuses to hospitalized, complete form for involuntary admission

10. lower risk  patients who are not suicidal, with no plan or access to lethal means  discuss protective factors and supports in their life, remind them of what they live for, promote survival skills that helped them through previous suicide attempts  make a safety plan- an agreement that will not harm themselves, avoid alcohol, drugs, and situations that may trigger suicidal thoughts, follow-up with you at a designated time, and contact a health care worker, call a crisis line or go to an emergency department if they feel unsafe or if their suicidal feelings return or intensify

11.  depression: hospitalize if severe or if psychotic figures are present; otherwise outpatient treatment with good supports and SSRIs and SNRIs  alcohol-related: usually resolves with abstinence for a few days, if not suspect depression  personality disorders: crisis intervention/ confrontation, may or may not hospitalize  schizophrenia/ psychosis: hospitalization

12.  parasuicide/ self- mutilation: long-term psychotherapy with brief crisis intervention when necessary  proper documentation of the clinical encounter and rationale for management is essential

13. The End