Suicidal ideation

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Suicidal ideation
Classification and external resources
Stückelberg Sappho 1897.jpg
Sappho (1897) by Ernst Stückelberg
ICD-10 R45.8
ICD-9 V62.84

Suicidal ideation concerns thoughts about or an unusual preoccupation with suicide. The range of suicidal ideation varies greatly from fleeting thoughts, to extensive thoughts, to detailed planning, role playing (e.g., standing on a chair with a noose), and unsuccessful attempts, which may be deliberately constructed to fail or be discovered, or may be fully intended to result in death, but the individual survives (e.g., for example in the case of a hanging in which the cord breaks).

Most people who undergo suicidal ideation do not go on to make suicide attempts, but it is considered a risk factor.[1] Suicidal ideation is generally associated with depression; however, it seems to have associations with many other psychiatric disorders, life events, and family events, all of which may increase the risk of suicidal ideation. Recurrent suicidal behavior and suicidal ideation is a hallmark of borderline personality disorder. One study found that 73% of patients with borderline personality disorder have attempted suicide, with the average patient having 3.4 attempts.[2] Currently, there are a number of different treatment options for those experiencing suicidal ideation.

Signs and symptoms[edit]

Suicidal ideation has a straightforward definition — suicidal thoughts — but there are some other related signs and symptoms. Some symptoms or co-morbid conditions may include unintentional weight loss, feeling helpless, feeling alone, excessive fatigue, low self-esteem, presence of consistent mania, excessively talkative, intent on previously dormant goals, feel like one's mind is racing.[3] The onset of symptoms like these with an inability to get rid of or cope with their effects, a possible form of psychological inflexibility, is one possible trait associated with suicidal ideation.[4] They may also cause psychological distress, which is another symptom associated with suicidal ideation.[5] Symptoms like these related with psychological inflexibility, recurring patterns, or psychological distress may in some cases lead to the onset of suicidal ideation. Other possible symptoms and warning signs include:

Scales[edit]

  • Beck Scale for Suicide Ideation
  • Columbia Suicide Severity Rating Scale
  • The Kessler Psychological Distress Scale (K10)
    • This test does not measure suicidal ideation directly, but there may be value in its administration as an early identifier of suicidal ideation. High scores of psychological distress are in some cases associated with suicidal ideation.[5]

Risk factors[edit]

There are numerous indicators that one can look for when trying to detect suicidal ideation. There are also situations in which the risk for suicidal ideation may be heightened. The risk factors for suicidal ideation can be divided into 3 categories: psychiatric disorders, life events, and family history.

Psychiatric disorders[edit]

There are several psychiatric disorders that appear to be comorbid with suicidal ideation or considerably increase the risk of suicidal ideation.[6] The following list includes the disorders that have been shown to be the strongest predictors of suicidal ideation. It should be noted, however, that these are not the only disorders that can increase risk of suicidal ideation. The disorders in which risk is increased the greatest include:[7]

Prescription drug side effects[edit]

Some prescription drugs, such as selective serotonin re-uptake inhibitors, can have suicidal ideation as a side effect. Moreover, these drugs' intended effects can themselves have the unintended or undesired consequence of an increased individual risk and collective rate of suicidal behavior: Among the set of persons taking the medication, a subset feel bad enough to want to commit suicide (or to desire the perceived results of suicide) but are inhibited by depression-induced symptoms, such as lack of energy and motivation, from following through with an attempt. Among this subset, a "sub-subset" may find that the medication alleviates their physiological symptoms (such as lack of energy) and secondary psychological symptoms (e.g., lack of motivation) before or at lower doses than it alleviates their primary psychological symptom of depressed mood. Among this group of persons, the desire for suicide and/or its effects persists even as major obstacles to suicidal action are removed, with the effect that the incidences of suicide attempt and of completed suicide increase.[citation needed]

Life events[edit]

Life events are strong predictors of increased risk for suicidal ideation. Furthermore, life events can also lead to or be comorbid with the previous listed psychiatric disorders and predict suicidal ideation through those means. Life events that adults and children face can be dissimilar and for this reason, the list of events that increase risk can vary in adults and children. The life events that have been shown to increase risk the greatest are[10]

  • Alcohol abuse
    • Studies have shown that individuals who binge drink, rather than drink socially, tend to have higher rates of suicidal ideation[11]
    • Certain studies associate those who experience suicidal ideation with higher alcohol consumption[4]
    • Not only do some studies show that solitary binge drinking can increase suicidal ideation, but there is a positive feedback relationship causing those who have more suicidal ideation to have more drinks per day in a solitary environment[11]
  • Certain studies associate those who experience suicidal ideation with unemployment[4]
  • Loss of family and/or friends
  • Other studies have found that tobacco use is correlated with depression and suicidal ideation[12]
  • Unplanned pregnancy
  • Bullying, including cyberbullying[13][14]
  • Previous suicide attempts
    • Having previously attempted suicide is one of the strongest indicators of future suicidal ideation or suicide attempts[11]
  • Military experience
    • Military personnel who show symptoms of PTSD, major depressive disorder, alcohol use disorder, and generalized anxiety disorder show higher levels of suicidal ideation[15]
  • Community violence[16]
  • Undesired changes in body weight[17]
    • Women: increased BMI increases chance of suicidal ideation
    • Men: severe decrease in BMI increases chance of suicidal ideation
      • In general, the obese population has increased odds of suicidal ideation in relation to individuals that are of average-weight
  • Exposure and attention to suicide related images or words[18]

Family history[edit]

  • Parents with a history of depression
    • Valenstein et al. studied 340 adult offspring whose parents had depression in the past. They found that 7% of the offspring had suicidal ideation in the previous month alone
  • Abuse[16]
    • Childhood: physical abuse
    • Adolescence: physical and sexual abuse
  • Family violence
  • Childhood residential instability
    • Certain studies associate those who experience suicidal ideation with family disruption.[4]

Relationships with parents and friends[edit]

According to a study conducted by Ruth X. Liu of San Diego State University, a significant connection was found between the parent–child relationships of adolescents ranging from early, middle and late adolescence and their likelihood of suicidal ideation. The study consisted of measuring relationships between mothers and daughters, fathers and sons, mothers and sons and fathers and daughters. The relationships between fathers and sons during early and middle adolescence shows an inverse relationship to suicidal ideation. Closeness with the father in late adolescence is "significantly related to suicidal ideation".[19] Liu goes on to explain the relationship found between closeness with the opposite sex parent and the child's risk of suicidal thoughts. It was found that boys are better protected from suicidal ideation if they are close to their mothers through early and late adolescence; whereas girls are better protected by having a close relationship with their father during middle adolescence.

An article published in 2010 by Zappulla and Pace found that suicidal ideation in adolescent boys is exacerbated by detachment from the parents when depression is already present in the child. Lifetime prevalence estimates of suicidal ideation among nonclinical populations of adolescents generally range from 60% and in many cases its severity increases the risk of completed suicide.[20]

Prevention[edit]

Early detection and treatment are the best ways to prevent suicidal ideation and suicide attempts. If signs, symptoms, or risk factors are detected early then the individual will hopefully seek treatment and help before attempting to take their own life. In a study of individuals who did commit suicide, 91% of them likely suffered from one or more mental illnesses. However, only 35% of those individuals were treated or being treated for a mental illness.[21] This emphasizes the importance of early detection; if a mental illness is detected, it can be treated and controlled to help prevent suicide attempts. Another study investigated strictly suicidal ideation in adolescents. This study found that depression symptoms in adolescents as early as grade 9 is a predictor of suicidal ideation. Most people with long-term suicidal ideation do not seek professional help.[citation needed]

The previously mentioned studies point out the difficulty that mental health professionals have in motivating individuals to seek and continue treatment. Ways to increase the amount of individuals who seek treatment may include:

  • Increasing the availability of therapy treatment in early stage
  • Increasing the public’s knowledge on when psychiatric help may be beneficial to them
    • Those who have adverse life conditions seem to have just as much risk of suicide as those with mental illness[21]

A study conducted by researchers in Australia set out to determine a course of early detection for suicidal ideation in teens stating that "risks associated with suicidality require an immediate focus on diminishing self-harming cognitions so as to ensure safety before attending to the underlying etiology of the behavior". A Psychological Distress scale known as the K10 was administered monthly to a random sample of individuals. According to the results among the 9.9% of individuals who reported "psychological distress (all categories)" 5.1% of the same participants reported suicidal ideation. Participants who scored "very high" on the Psychological Distress scale "were 77 times more likely to report suicidal ideation than those in the low category".[5]

In a 1-year study conducted in Finland, 41% of the patients who later committed suicide saw a health care professional, most seeing a psychiatrist. Of those, only 22% discussed suicidal intent on their last office visit. In most of the cases, the office visit took place within a week of the suicide, and most of the victims had a diagnosed depressive disorder.[22]

There are many centers where one can receive aid in the fight against suicidal ideation and suicide. Hemelrijk et al. (2012) found evidence that assisting people with suicidal ideation via the internet versus more direct forms such as phone conversations has a greater effect.

Treatment[edit]

Treatment of suicidal ideation can be puzzling due to the fact that several medications have actually been linked to increasing or causing suicidal ideation in patients. Therefore, several alternative means of treating suicidal ideation are often used. The main treatments include: hospitalization, outpatient treatment, and medication/other modalities.[23]

Hospitalization[edit]

Hospitalization allows the patient to be in a secure, supervised environment to prevent their suicidal ideation from turning into suicide attempts. In most cases, individuals have the freedom to choose which treatment they see fit for themselves. However, there are several circumstances in which individuals can be hospitalized involuntarily. These circumstances are:

  1. If an individual poses danger to self or others
  2. If an individual is unable to care for one's self

Hospitalization may also be the best treatment if an individual:

  • Has access to lethal means (e.g., a firearm or a stockpile of pills)
  • Does not have social support or people to supervise them
  • Has a suicide plan
  • Has symptoms of a psychiatric disorder (e.g.,psychosis, mania, etc)

Outpatient treatment[edit]

Outpatient treatment allows individuals to remain at their place of residence and receive treatment when needed or on a scheduled basis. Being at home may improve quality of life for some patients, because they will have access to their books and computer, and be able to come and go freely. Before allowing patients the freedom that comes with outpatient treatment, physicians evaluate several factors of the patient. These factors include the patient's level of social support, impulse control and quality of judgment. After the patient passes the evaluation, they are often asked to consent to a "no-harm contract". This is a contract formulated by the physician and the family of the patient. Within the contract, the patient agrees not to harm themselves, to continue their visits with the physician, and to contact the physician in times of need.[23] There is some debate as to whether "no-harm" contracts are effective. These patients are then checked on routinely to assure they are maintaining their contract and avoiding dangerous activities (drinking alcohol, driving fast without wearing a seat belt, etc).

Medication[edit]

Prescribing medication to treat suicidal ideation can be difficult. One reason for this is that many medications lift patients' energy levels before lifting their mood. This puts them at greater risk of following through with attempting suicide. Additionally, if a patient has a co-morbid psychiatric disorder, it may be difficult to find a medication that addresses both the psychiatric disorder and suicidal ideation. Therefore, the medication prescribed to one suicidal ideation patient may be completely different from the medication prescribed to another patient. However, there are several medications that seem to work fairly well for treating suicidal ideation:[23]

Antidepressants have been shown to be a very effective means of treating suicidal ideation. One correlational study compared mortality rates due to suicide to the use of SSRI antidepressants within certain counties. The counties which had higher SSRI use had a significantly lower number of deaths caused by suicide.[24] Additionally, an experimental study followed depressed patients for one year. During the first six months of that year, the patients were examined for suicidal behavior including suicidal ideation. The patients were then prescribed antidepressants for the six months following the first six observatory months. During the six months of treatment, experimenters found suicide ideation reduced from 47% of patients down to 14% of patients.[25] Thus, it appears from current research that antidepressants have a helpful effect on the reduction of suicidal ideation.

Although research is largely in favor of the use of antidepressants for the treatment of suicidal ideation, in some cases antidepressants are claimed to be the cause of suicidal ideation. Upon the start of using antidepressants, many clinicians will note that sometimes the sudden onset of suicidal ideation may accompany treatment. This has caused the food and drug administration to issue a warning stating that sometimes the use of antidepressants may actually increase the thoughts of suicidal ideation.[24] Medical studies have found antidepressants help treat cases of suicidal ideation and work especially well with psychological therapy.[26] Lithium[27] and Clozapine [28] have both been shown to reduce suicidal ideation. The Times quotes Dr. Herbert Meltzer suggesting "clozapine might turn out to be effective for suicidal patients with other illnesses like manic depression...or depression." [29]

See also[edit]

References[edit]

  1. ^ Gliatto, MF; Rai, AK (March 1999). "Evaluation and Treatment of Patients with Suicidal Ideation". American Family Physician 59 (6): 1500–6. PMID 10193592. Retrieved 2007-01-08.  open access publication - free to read
  2. ^ Soloff, PH; Kevin, GL; Thomas, MK; Kevin, MM; Mann, JJ (1 April 2000). "Characteristics of Suicide Attempts of Patients With Major Depressive Episode and Borderline Personality Disorder: A Comparative Study". American Journal of Psychiatry 157 (4): 601–608. doi:10.1176/appi.ajp.157.4.601. PMID 10739420. 
  3. ^ American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  4. ^ a b c d Valenstein, H; Cronkite, RC; Moos, RH; Snipes, C; Timko, C (2012). "Suicidal ideation in adult offspring of depressed and matched control parents: Childhood and concurrent predictors". Journal of Mental Health 21 (5): 459–468. doi:10.3109/09638237.2012.694504. PMID 22978501. 
  5. ^ a b c Chamberlain, P; Goldney, R; Delfabbro, P; Gill, T; Dal Grande, L (2009). "Suicidal Ideation: The Clinical Utility of the K10". Crisis. 1 30 (1): 39–42. doi:10.1027/0221-5910.30.1.39 (inactive 2014-03-04). PMID 19261567. 
  6. ^ Hemelrijk, E; Van Ballegooijen, W; Donker, T; Van Straten, A; Kerkhof, A (2012). "Internet-based screening for suicidal ideation in common mental disorders". Crisis: the Journal of Crisis Intervention and Suicide Prevention 33 (4): 215–221. doi:10.1027/0227-5910/a000142. PMID 22713975. 
  7. ^ Harris, EC; Barraclough, B (1997). "Suicide as an outcome for mental disorders. A meta analysis". The British Journal of Psychiatry 170: 205–228. doi:10.1192/bjp.170.3.205. PMID 9229027. 
  8. ^ Lemon, TI; Shah, RD (2013). "Needle exchanges – a forgotten outpost in suicide and self-harm prevention". Journal of Psychosomatic Research 74 (6): 551–552. doi:10.1016/j.jpsychores.2013.03.057. (subscription required (help)). 
  9. ^ Lemon, TI (2013). "Suicide ideation in drug users and the role of needles exchanges and their workers". Journal Psych Med 6 (5): 429. doi:10.1016/j.ajp.2013.07.003. PMID 24011693. 
  10. ^ Fergusson, DM; Woodward, LJ; Horwood, LJ (2000). "Risk factors and life processes associated with the onset of suicidal behavior during adolescence and early adulthood". Psychological Medicine 30 (1): 23–39. doi:10.1017/s003329179900135x. PMID 10722173. 
  11. ^ a b c Gonzalez, VM (2012). "Association of solitary binge drinking and suicidal behavior among emerging adult college students". Psychology of Addictive Behaviors 26 (3): 609–614. doi:10.1037/a0026916. PMC 3431456. PMID 22288976.  open access publication - free to read
  12. ^ Dugas, E; Low, NP; Rodriguez, D; Burrows, S; Contreras, G; Chaiton, M et al. (2012). "Early Predictors of Suicidal Ideation in Young Adults". Canadian Journal of Psychiatry 57 (7): 429–436. PMID 22762298. 
  13. ^ "Cyberbullying Research Summary – Cyberbullying and Suicide". Cyberbullying Research Center. Retrieved 3 July 2012. 
  14. ^ "The relationship between bullying, depression and suicidal thoughts/behaviour in Irish adolescents". Department of Health and Children. Retrieved 3 July 2012. 
  15. ^ Richardson, JD; St Cyr, KC; McIntyre-Smith, AM; Haslam, D; Elhai, JD; Sareen, J (2012). "Examining the association between psychiatric illness and suicidal ideation in a sample of treatment-seeking Canadian peacekeeping and combat veterans with posttraumatic stress disorder PTSD". Canadian Journal of Psychiatry 57 (8): 496–504. PMID 22854032. 
  16. ^ a b Thompson, R; Litrownik, AJ; Isbell, P; Everson, MD; English, DJ; Dubowitz, H et al. (2012). "Adverse experiences and suicidal ideation in adolescence: Exploring the link using the LONGSCAN samples". Psychology of Violence 2 (2): 211–225. doi:10.1037/a0027107. PMC 3857611. PMID 24349862.  open access publication - free to read
  17. ^ Carpenter, KM; Hasin, DS; Allison, DB; Faith, MS (2000). "Relationships between obesity and DSM-IV major depressive disorder, suicidal ideation, and suicide attempts: Results from a general population study". American Journal of Public Health 90 (2): 251–257. doi:10.1080/00048670902970825. PMID 19530022. 
  18. ^ Cha, CB; Najmi, S; Park, JM; Finn, CT; Nock, MK (2010). "Attentional bias toward suicide-related stimuli predicts suicidal behavior". Journal of Abnormal Psychology 119 (3): 616–622. doi:10.1037/a0019710. PMC 2994414. PMID 20677851.  open access publication - free to read
  19. ^ Liu, Ruth X. (December 2005). "Parent-Youth Closeness and Youth's Suicidal Ideation; The Moderating Effects of Gender, Stages of Adolescence, and Race or Ethnicity". Youth & Society 37 (2): 160–162. doi:10.1177/0044118X04272290. 
  20. ^ Zappulla, Carla. "Relations between suicidal ideation, depression, and emotional autonomy from parents in adolescence". Springer Science + Business Media LLC. Retrieved 10 April 2012. 
  21. ^ a b Cavanagh, JO; Owens, DC; Johnstone, EC (1999). "Life events in suicide and undetermined death in south-east Scotland: a case-control study using the method of psychological autopsy". Social Psychiatry and Psychiatric Epidemiology 34 (12): 645–650. doi:10.1007/s001270050187. PMID 10703274. 
  22. ^ Halgin, Richard P.; Susan Whitbourne (2006). Abnormal psychology: clinical perspectives on psychological disorders. Boston: McGraw-Hill. pp. 267–272. ISBN 0-07-322872-9. 
  23. ^ a b c Gliatto, MF; Rai, AK (1999). "Evaluation and treatment of patients with suicidal ideation". American Family Physician 59: 1500–1513.  [clarification needed]
  24. ^ a b Simon, GE (2006). "How can we know whether antidepressants increase suicide risk?". American Journal of Psychiatry 163 (11): 1861–1863. doi:10.1176/appu.ajp.163.11.1861 (inactive 2014-03-04). PMID 17074930. 
  25. ^ Mulder, RT; Joyce, P. R.; Frampton, C. M. A.; Luty, S. E. (2008). "Antidepressant treatment is associated with a reduction in suicidal ideation and suicide attempts". Acta Psychiatrica Scandinavica 118 (12): 116–122. doi:10.1111/j.1600-0447.2008.01179.x. PMID 18384467. 
  26. ^ Zisook, S; Lesser, IM; Lebowitz, B; Rush, AJ; Kallenberg, G; Wisniewski, SR et al. (2011). "Effect of antidepressant medication treatment on suicidal ideation and behavior in a randomized trial: An exploratory report from the Combining Medications to Enhance Depression Outcomes Study". Journal of Clinical Psychiatry 72 (10): 1322–1332. doi:10.4088/JCP.10m06724. PMID 22075098. 
  27. ^ Cipriani A, Hawgon K, Stockton S, et al. (27 June 2013). "Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis". BMJ 346 (jun27 4): f3646–f3646. doi:10.1136/bmj.f3646. PMID 23814104. 
  28. ^ CNS Drugs. 2003;17(4):273-80; discussion 281-3. Clozapine: in prevention of suicide in patients with schizophrenia or schizoaffective disorder. Wagstaff A1, Perry C.
  29. ^ http://www.ahrp.org/infomail/1202/20.php

Further reading[edit]

  • Beck, AT; Steer, RA; Kovacs, M; Garrison, B (1985). "Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation". Am J Psychiatry 142 (5): 559–563. PMID 3985195. 
  • Uncapher, H (2000–2001). "Cognitive biases and suicidal ideation in elderly psychiatric inpatients". Omega 42 (1): 21–36. doi:10.2190/6uu8-hk8e-hl0v-q4cu. 
  • Uncapher, H; Gallagher-Thompson, D; Osgood, NJ (1998). "Hopelessness and suicidal ideation in older adults". The Gerontologist 38 (1): 62–70. doi:10.1093/geront/38.1.62. PMID 9499654. 

External links[edit]