Rosen & Barkin's 5-Minute Emergency Medicine Consult (686 page)

798.0 Sudden infant death syndrome

BASICS

• The intentional taking of one’s own life
  
• Suicidal ideation:
  
  • Passive: A conscious desire not to live
    
  • Active: Intention to die with or without a plan
    
• Parasuicidal behavior: Self-injury not intended to cause death (e.g., superficial cutting, cigarette burns, head banging)
  
• Reckless behavior: Not taking prescribed medications, taking too much of prescribed medications, running into traffic
  
• Risk-to-rescue ratio—lethality of plan compared with likelihood of rescue:
  
  • High risk-to-rescue ratio indicates increased severity of attempt.
    
• Occult presentation:
  
  • Many individuals at risk for suicidal behavior seek care in the ED for nonbehavioral complaints
    
  • Improved suicide screening practices may be needed to capture this population.
    

• 36,891 suicides in US (CDC 2009)
  
• 12–25 attempts per every completed suicide
  
• 25.4 per 100,000 males (CDC 2009)
  
• 7.4 per 100,000 females
  
• 11.1 per 100,000 general population
  
• 2 peaks in age group most at risk for suicide:
  
  • Age 15–24 yr (3rd leading cause of death in this age group)
    
  • Age >60 yr (highest rates of any age group, increasing incidence with age)
    

• Depression (bipolar or unipolar)
  
• Alcohol or drug abuse
  
• History of physical or sexual abuse
  
• Unemployment
  
• Incarceration
  
• History of head injury or neurologic disorder
  
• Firearms in the home
  
• Cigarette smoking
  
• Positive family history of suicide attempt
  
• Psychiatric or medical comorbidities
  
• Gender:
  
  • Women 3 times more likely to attempt suicide.
    
  • Men 3 times more likely to complete suicide.
    
• Psychological:
  
  • Impulsivity/aggression
    
  • Depression
    
  • Anxiety
    
  • Hopelessness
    
  • Self-consciousness/social disengagement
    
  • Poor problem-solving abilities
    
  • Lack of social supports
    
  • Widowed
    
  • Divorced
    
  • Separated
    
  • Lack of social supports
    
  • Recent loss of relationship
    
  • Anniversary of loss
    
• Environmental
  
• Rural areas:
  
  • Access to firearms
    
  • Poverty
    
  • Unemployment
    

• Male
  
• Age >60 yr
  
• White or Native American
  
• Widowed/divorced
  
• Living alone
  
• Unemployment/poverty
  
• Past suicide attempt
  

• Firearms (most common among men and 2nd most common in women)
  
• Overdose (Most common among women); most common means of suicide attempt (70% of failed attempts are by overdose)
  
• Hanging
  
• Suffocation
  

• >90% of patients who commit suicide have a psychiatric diagnosis.
  
• Depression—especially psychotic depression
  
• Anxiety and panic disorder
  
• Alcohol or drug intoxication
  
• Schizophrenia
  
• Adolescents
  

• Recent discharge from psychiatric facility
  
• History of suicidal ideation or suicide attempt
  
• Serious physical illness present in up to 70% of all suicides, particularly in elderly patients.
  
• History of incarceration
  
• Physicians
  
• Victims of violence/abuse
  

• Patients with mood disorders (major depression and bipolar disorder) treated with lithium
  
• Patient with major depression treated with electroconvulsive therapy
  
• Patients with schizophrenia treated with clozapine
  
• NOT
  shown to decrease suicide rates: Treatment with selective serotonin reuptake inhibitors (SSRIs) for major depression
  

• Strong social supports
  
• Family cohesion
  
• Peer group affiliation
  
• Good coping and problem-solving skills
  
• Positive values and beliefs
  
• Ability to seek and access help
  

DIAGNOSIS

• Depressed mood
  
• Verbalization of suicidal ideation with or without plan
  
• Hopelessness
  
• Helplessness
  
• Anger/aggression
  
• Impulsivity
  
• Psychotic symptoms (i.e., paranoia, command auditory hallucinations)
  

• Obtain history to assess risk:
  
  • Asking about suicide does not increase risk for attempt
    
• Degree of suicidal ideation
  
• Plan immediate risk of self-injury?
  
  • Means available to complete plan
    
  • Activity toward initiating plan
    
  • Patient’s expectations of lethality of plan
    
• Intent: Reasons, goal
  
• Risk-to-rescue ratio
  
• Plan or intent to harm others?
  
• Presence of acute precipitants:
  
  • Recent losses, lack of social supports
    
• Risk factors:
  
  • History of past suicide attempts
    
  • Psychiatric review of symptoms: Depression, psychosis, panic/anxiety
    
  • Chronic medical illness
    
  • Alcohol or drug abuse
    
• Serial assessment of mental status, consistency of responses
  
• Factors preventing suicide
  

• As needed to address acute medical issues
  
• Look for evidence of injuries and signs of self-neglect.
  

• Modified SAD PERSONS Score:
  
  • Sex: Male 1 point
    
  • Age <19 or >45 yr 1 point
    
  • Depression or hopelessness 2 points
    
  • Previous attempts or psychiatric care 1 point
    
  • Excessive alcohol or drug use 1 point
    
  • Rational thinking loss 2 points
    
  • Separated/divorced/widowed 1 point
    
  • Organized or serious attempt 2 points
    
  • No social supports 1 point
    
  • Stated future intent 2 points
    
  • Data suggests that patients with a score of <5 can safely be managed as an outpatient
    

• Collateral information from outpatient care givers, family, friends
  
• Safety plan:
  
  • Would the patient immediately seek help if suicidal ideation recurred?
    
  • Elimination of means of suicide
    
  • Access to other means of suicide
    
  • Support and supervision in the outpatient setting
    
  • Prompt outpatient follow-up with psychiatric therapy
    
  • Patient investment in not attempting suicide
    
  • Identifying reasons for living
    
  • Safety contracts are no guarantee that individuals will not attempt suicide.
    

• Blood–alcohol level
  
• Serum toxicology screen: Aspirin, acetaminophen, and other medications
  
• Urine drug screen:
  
  • Many psychiatric facilities require toxicology screen before placement.
    
• Carbon monoxide (as indicated)
  

Not routinely indicated

ECG – as indicated

• Normal despondency
  
• Bereavement
  
• Adjustment disorder with depressed mood
  
• Major depressive disorder
  
• Bipolar disorder
  
• Organic mental disorder (head injury, dementia, delirium)
  
• Schizophrenia
  
• Panic and anxiety disorders
  
• Alcohol or drug abuse
  
• Borderline personality disorder
  
• Antisocial personality disorder
  
• Accidental death
  
• Attempted homicide
  

• Suicide is a leading cause of death among young people 15–24 yr of age.
  
• More than 4,000 adolescents commit suicide every year (CDC 2009)
  
• Rapidly increasing in young black males ages 10–14 yr
  
• Less evidence available to link suicide in youth to overt psychiatric illness
  
• Stresses:
  
  • Prior attempts
    
  • Family disruption
    
  • History of psychiatric disorder
    
  • Depression
    
  • Disciplinary crisis
    
  • Broken romance
    
  • School difficulties
    
  • Bereavement
    
  • Rejection
    
  • History of physical or sexual abuse
    
• Early warning signs:
  
  • Progressive declining schoolwork
    
  • Multiple physical complaints
    
  • Substance abuse
    
  • Disrupted family relations
    
  • Social withdrawal
    
  • Anhedonia
    

• Suicide rates highest in age >65 yr
  
• Completed suicide: 83% men
  
• Risk factors: Divorced, widowed, male, social isolation
  
• Tend to use more lethal methods
  
• Lower ratio of attempts to completions
  

TREATMENT