Suicide

You’ve just seen a patient who attempted to overdose on Tylenol. His exam is normal and you think he’ll be alright. However, you would like to admit for the suicide attempt. Of course you just filled the last bed in the psych unit two hours earlier and will now have to find an accepting facility to transfer the patient. You wonder: What are the chances that this patient will actually go on to commit suicide? Are there any ways to risk stratify these patients?

 

 

Review by Ryan Petersen, M.D.
Column organized by Evan Schwarz, M.D.
Washington University in St. Louis
Division of Emergency Medicine

 

Doshi, A, Boudreaux, ED, Wang N, et al.  National Study of US emergency department visits for attempted suicide and self-inflicted injury, 1997-2001.  Ann Emerg Med.  Oct 2005; 46 (4):  369-375.

 

While working an evening shift in the emergency department you encounter an 18-year-old female who has attempted suicide by Tylenol ingestion.  Her exam is unremarkable, but her past history is significant for depression and alcohol abuse.  As you order labs, you wonder what type of patient typically presents with a suicide attempt, what means do they use, and if they are at a greater risk to complete suicide.

Suicide is the eighth leading cause of death within the United States, and is responsible for approximately 30,000 deaths annually. It accounts for more than 400,000 ED visits per year. The majority of epidemiologic studies have focused on completed suicide rather than on suicide attempt or intentional self-injury.  The attempted to completed suicide ratio is 8:1, thus many of these studies fail to define the typical case that presents to an emergency department.  This article employs data from the National Hospital Ambulatory Medical Care Survey to further define this population of patients.

Visits for attempted suicide and self-inflicted injury accounted for 0.4% of the total ED visits between 1997 and 2001.  ED visits varied according to age, sex, and race.  The mean patient age was 31 years old and visits were most common among 15 to 19 year olds.

 

Age	Rate (per 1,000 ED visits)
15-19 years old   ADVERTISEMENT	3.3
20-29 years old	2.9
30-49 years old   ADVERTISEMENT	2.0
Sex
Males   ADVERTISEMENT	1.3
Females	1.7
Race
White	1.5 ADVERTISEMENT
African American	1.9

 

However other studies concluded that whites have a higher rate of suicide attempts than African Americans.  The most common method of attempted suicide was poisoning (68%), cutting/piercing instruments (20%), hanging (<1%) and firearms (<1%).

Suicide attempts were associated with psychiatric disorders and alcohol abuse.  Psychiatric disorders were coded in 55% of those presenting with a suicide attempt, with depressive disorder being present in 18%. Alcohol abuse was present in 9%.  Between 40-60% of people who commit suicide are intoxicated at death.  With psychiatric conditions and intoxication being so prevalent in this population, it is very important to document mental status exam and suspicion of intoxication if an alcohol level is not ordered.  Only 43% of charts included a mental status exam and only 25% had an ethanol level.  Suicide is the third leading cause of death among 15 to 24 years olds.  This may be due to factors such as self-doubt, pressure to succeed, and role confusion.  Either way the ED may be their first point of contact with health care in order to get help. 

The populations of patients who present with suicide attempt vary greatly when compared to those who have completed suicide.  Patients who complete suicide are typically older, men, living alone, physically ill, and utilize a more lethal means of suicide.  In contrast, those who attempt suicide are younger, women with psychosocial risk factors such as depression, substance abuse, and other mental disorders.  It should be kept in mind that these patients can still have significant injuries as one third are admitted with one third of those being admitted to the ICU.  Evidence suggests that those who present with a suicide attempt have a significant risk of eventually completing suicide.  As emergency department physicians, we have a unique task of identifying these patients.  This is made more challenging as attempted suicide trended to be more common at night than the trend for overall ED visits when many of the resources these patients need may not be available.  Scales such as the SAD PERSONS and Manchester Self-Harm Rule are available to help risk stratify patients.  Proper assessment and clinical management may help prevent suicide and future suicide attempts.