Between 11 and 17% of people who have suffered a severe depressive disorder at any time will eventually commit suicide. About 1% of deaths in England and Wales each year are due to suicide, yielding a rate of 8 per 100000.
Recent bereavement, separation or divorce
Recent loss of a job or retirement
Living in a socially disorganized area
Family history of affective disorder, suicide or alcohol abuse
Previous history of affective disorder, alcohol or drug abuse
Previous suicide attempt
Addiction to alcohol or drugs
Severe depression or early dementia
Incapacitating, painful physical illness
Factors that increase the risk of suicide.
The rate increases with age, peaking for women in their sixties and for men in their seventies. However, in recent years the suicide rate in young people, particularly young men, has been rising steadily throughout western Europe. The highest rates of suicide have been reported in Hungary (40 per 100000), while the lowest are those of Spain (3.9 per 100000) and Greece (2.8 per 100000), but such variations may reflect differences in reporting as much as genuine differences in frequency of suicide. Factors that increase the risk of suicide are indicated in Table 19.20.
A distinction must be drawn between those who attempt suicide (parasuicides) and those who are determined and eventually succeed (suicides). The following points should be considered:
• Suicide is commoner in men, while parasuicide is commoner ill women.
• The majority of parasuicides occur in people under 35 years of age.
• The majority of suicides occur in people over 60 years of age.
• Approximately 90% of parasuicides involve selfpoisoning.
• A formal psychiatric disorder is unusual in parasuicide.
There is, however, overlap between the two groups and between 1 and 2% of people who attempt suicide will kill themselves in the year following their original attempt.
Questions to ask
Was there a clear precipitant/cause for the attempt?
What was the patient’s state of mind at the time?
Was the act premeditated or impulsive?
Did the patient leave a suicide note?
Had the patient taken pains not to be discovered?
Did the patient make the attempt in familiar or strange surroundings (i.e. at home or away from home)?
What are the patient’s feelings about the attempt now? Would they do it again?
Was the patient under the influence of alcohol or drugs?
Other relevant factors
Has the precipitant or crisis resolved?
Is there continuing suicidal intent?
Does the patient have any psychiatric symptoms?
What is the patient’s social support system?
Hasthe patient inflicted self-harm before?
Has anyone in the family ever taken their life?
Does the patient have a physical illness?
Indications for referral to a psychiatrist
Absolute indications include:
Psychotic illness of any kind
Clearly preplanned suicidal attempts which were not intended to be discovered
Persistent suicidal intent (the more detailed the plans, the more serious the risk)
A violent method used
Other common indications include:
Alcohol and drug abusers
Older patients over 45 years, especially if male, and young adolescents
Those with a family history of suicide in first-degree relatives
Those with serious (especially incurable) physical disease
Those living alone or otherwise unsupported
Those in whom there is a major unresolved crisis
Persistent suicide attemptors
Any patients who give you cause for concern
Guidelines for the assessmentof patients with deliberate self-harm.
In the UK, over 100000 suicide attempts are made each year, and the overwhelming majority of these are seen and treated within accident and emergency departments. The guidelines given in Information box 19.3 for the assessment of such patients will help ensure that the risk factors relating to suicide are covered. Indications for referral to a psychiatrist before discharge from hospital are also given.
In general, it is worth trying to interview a family member or other close associate and check these points with him or her. Requests for immediate re-prescription or discharge should be denied, except in cases of essential medication (e.g. epileptics). In such cases, however, only 3 days’ supply of medication should be given and the patient should be instructed to report to their general practitioner or to their psychiatric outpatient clinic for further supplies.