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Suicide and attempted suicide

Most cases of suicide are tragedies for the person who commits suicide and their family. In some instances a successful suicide represents a failure by the medical profession if the GP has been consulted in the period prior to the act. There are some cases of suicide in the terminally ill patient, in significant pain, that may not be considered to be such a tragedy. ³

In many cases the description ‘attempted suicide’ is inaccurate, as there was no clear intent to die. For this reason, attempted suicides are often referred to deliberate self harm (DSH) - the term parasuicide is not widely used now. Of course, some cases of intended DSH turn into suicide, often related to the unappreciated toxicity of paracetamol and tricyclic antidepressants in overdose. Around 30-40% of suicides have made an earlier attempt. A large proportion of attempted suicides is by an overdose of commonly available drugs such as aspirin, paracetamol, antidepressants and minor tranquillisers, often in conjunction with alcohol. ⁴

Epidemiology
Incidence The UK has a relatively low suicide rate of 7.1/100,000 of the population per annum compared to many other countries. France has an incidence of 20.6, Lithuania 48.2 and the USA11.9.

Using a ratio of 15:1 for attempted vs. completed suicides given an incidence of ~1/1000 population/year.

Risk factors The largest risk factor is a major psychiatric illness (90% cases), especially schizophrenia, severe depression and alcohol or drug dependence. There are various other factors that increase the risk of suicide:

• A direct statement of intent – it is not true that people who talk of suicide do not do it
• Previous suicide attempt
• Older patients - especially those alone and suffering chronic pain
• Family history of suicide
• Patient living alone
• Unemployment
• Financial difficulties
• Recent negative events – divorce, redundancy, diagnosis of serious illness
• Imprisonment.

Management
Suicide Confirm death and report the death to the Coroner and the police immediately. Offer counselling and support to the family.

Attempted suicide Ideally anyone presenting with DSH should have a psychiatric risk assessment (Pierce suicidal intent scale bgp8437). Often the level of overdose does not closely reflect the degree of suicidal intent. The patient can then be interviewed in hospital the next day or as soon as they are coherent. The first task is to decide if this was a genuinely unsuccessful attempt or not and assess whether there is a continuing intention to suicide. Part of this is looking at the circumstances of the attempt, e.g. how large was the overdose and was help expected. The other component is interviewing the patient, which must be conducted in a sympathetic, open and non-judgemental manner giving the patient time to talk. Initially, many patients are unwilling to discuss the attempt and need patience in getting them to reveal their feelings. Where a serious attempt was made and the patient no longer appears suicidal, this should not be taken at face value as they may be hiding their true intentions or suffering a temporary improvement in their mood.

An important part of the interview is to discover their motivation for suicide and especially to detect any depression that may be present. This then leads on to discussion of their suicidal ideation. A typical series of questions would be:

• Have you any hope that everything will turn out alright?
• Do you derive any pleasure from your life?
• How do you feel about facing each day – hopeful?
• Do you see any point in life?
• Do you ever feel that you can’t face tomorrow?
• Is life a burden to you?
• Do you know why you feel this way?
• For how long and how often have you thought about ending your life?
• What ways have you thought about how you might do it?
• Have you done anything about it other than this attempt?
• Do you think you might do it again?
• Is there anything that might prompt you?
• Is there anyone who you can ask for help?
• Do you think you might harm someone else?

An informed decision on the risk of further attempts can be made and the appropriate therapeutic course embarked upon, including sectioning under the Mental Health Act if necessary.

References Used

1. Oxford Textbook of Primary Medical Care. Eds Jones R et al. OUP 2004.
2. Concise Oxford Textbook of Medicine. Weatherall D et al. Oxford University Press 2000
3. Chetwynd SB; Right to life, right to die and assisted suicide.;J Appl Philos 2004;21(2):173-82.[abstract]
4. Hawton K, Harriss L, Simkin S, et al; Self-cutting: patient characteristics compared with self-poisoners.;Suicide Life Threat Behav 2004 Autumn;34(3):199-208.[abstract]

Internet and Further Reading

• Oxford University  Oxford Centre for Suicide Research

Acknowledgements EMIS is grateful to doctoronline.nhs.uk for facilitating draft authoring of this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2005.

Last issued 11 May 2005