General Medical Officer (GMO) Manual: Clinical Section

Suicide

Department of the Navy
Bureau of Medicine and Surgery

Suicide is the ninth leading cause of death in the United States, resulting in 30,000 deaths annually. The overall rate has been fairly constant for the past several years at between 11 and 12 per 100,000 people. More importantly for the GMO, however, are the facts that suicide is one of the leading causes of death among healthy young males, and that the rate of suicide in this group is actually going up (being offset by a decline in the rate of suicide among older people). Among males, the rate of completed suicide peaks between ages 20 and 40, then declines until after age 65, when it peaks again. For every one person who completes a suicide, about 23 will attempt it. Clearly, the high-stress operational naval environment is populated largely with high-risk young males who are recently removed from their customary sources of support. As a result, suicide attempts, gestures, and completions are problems of the utmost importance.

A first step in the prevention of suicide is determining who is at risk for suicidal behavior. One cannot rely on statements of suicidal ideation alone, since many people commit suicide without ever telling anyone what they intended to do, and many others use suicide threats as a means of manipulating their environments without much genuine intent for suicide. Likewise, one cannot equate a "contract for safety" (promise by a potentially suicidal patient that he will not harm himself) with a low suicide risk since genuinely suicidal people sometimes act on their suicidal impulses even after promising not to, and a contract for safety confers no medicolegal protection for the physician who evaluated the suicidal patient. The key is to maintain a high index of suspicion regarding suicide risk whenever evaluating patients who present with emotional, mental, behavioral, or occupational problems, and then to perform a thorough, objective assessment of suicidal risk on every patient for whom it is even remotely is an issue.

Suicide risk assessment is a three-step process. First, one adds up all the factors present in a particular patient which are known to be correlated with suicide. Second, one weighs these suicide risk factors against the factors also present in that patient that mitigate against suicide. Third, one documents the first two steps in the medical record, along with a summary assessment of overall risk.

The following list outlines known suicide risk factors:

• having a workable suicide plan with access to a lethal means

• history of prior suicide attempts, gestures, or threats

• male gender

• advanced age

• a recent significant loss (e.g., relationship break-up or death of a loved one)

• being unmarried

• being unskilled or unemployed (in the military, pending separation from the service counts here)

• having a disorder of drug or alcohol use

• having a chronic physical illness or chronic pain

• having a mood disorder (depression or mania)

• being psychotic

• having a severe personality disorder or chronic problems with impulse control

• having a family history of suicide

• having experienced the suicide of a friend, relative, or coworker

Every patient who possesses several of the previously mentioned risk factors for suicide should be considered potentially at risk for suicide, whether suicide threats are communicated or not. In every such case, an active query should be made regarding suicidal thoughts, wishes, fantasies, impulses, and dreams. If a workable, potentially lethal suicide plan is disclosed, suicide risk should be considered high.

These are many fewer in number, but are no less important. The first of these is social support. Individuals who have access to genuine emotional support from caring friends, family, peers, or professionals are usually less likely to act on their suicidal impulses than those who are socially isolated. The second protective factor is hope. People can endure nearly limitless pain (physical and/or psychic) and social isolation if they have hope that their burden will lessen at some point in the future. Once hope is lost, suicide becomes much more likely. Another protective factor is holding active religious beliefs that prohibit suicide.

Every patient whose suicide risk is deemed to be high, or whose suicide risk remains uncertain due to a lack of reliable information, should be maintained on a continuous suicide watch until he or she can be evaluated by a mental health professional. If such an individual attempts to leave the clinic, hospital, or sick bay before psychiatric evaluation, he or she should be physically detained and restrained, if necessary, as a humanitarian measure. Every patient who has made a recent suicide attempt or gesture should also be referred for mental health evaluation, although the urgency of the referral should be based on an assessment of other risk factors. When in doubt, don’t take chances: consult your nearest mental health provider.

1. NAVMEDCOMINST 6520.