Primary Care and Suicide Prevention
Which clinical clues identify patients at greatest risk for suicide?
Primary care is demanding for a host of reasons, not the least of which is the daunting breadth of issues practitioners grapple with. One issue is evaluating the risk of suicide. Two recent studies provide some intriguing data that may change the way we practice.
RISK HIGHER WITH MORE LETHAL METHODS
In a cohort study (with a follow-up of 21 to 31 years), Runeson and colleagues1 looked at whether there was a correlation between the method of attempted suicide and a successful subsequent attempt. In this cohort, 48,649 persons were admitted to the hospital between 1973 and 1982 after an unsuccessful suicide attempt. Of this group, 5740 (12%) committed suicide after the first unsuccessful attempt.
Although poisoning was the most common method used for attempted suicide (83.8%), it was least likely to be associated with later successful suicides. For those who attempted suicide by more lethal methods on the first attempt, the hazard ratio for a second, successful attempt later was alarming. After unsuccessful hanging, strangulation, or suffocation attempts, the hazard ratio for later suicide was 6.2 times greater; after drowning, 4.0; jumping from a height or use of a firearm or an explosive, 3.2; gassing, 1.8; and cutting or piercing, 1.0. Other contributing factors included having a psychotic disorder, an affective disorder, or other psychiatric disorder. Furthermore, those who committed later suicide often used the same method as before.
The study had weaknesses: it included only attempts that eventuated in hospitalization, and potential contributing factors such as unemployment were not included. Overall, however, the results suggest that persons who attempt suicide by more lethal methods warrant careful follow-up.
ASTHMA: AN OVERLOOKED RISK FACTOR?
Kuo and coworkers2 addressed a possible connection between asthma and the risk of suicide. A total of 12,766 high school students in Taiwan were studied over a 12-year period. The cohort was separated into 3 groups: those with current asthma, previous asthma, and no history of asthma.
Suicide was more than twice as common in students with asthma compared with those who did not have the disease. There was no difference in the incidence of natural deaths between these 2 groups. Among students with a greater number of asthma symptoms at baseline, the rate of suicide was higher. Weaknesses of the study included self-reporting of asthma symptoms, a homogenous national cohort (Taiwanese), and questions about the accurate reporting of suicide versus accident.
Although primary care evaluations are already loaded with pertinent information, these 2 “Top Papers” may have added some new data. Asking whether there has been a suicide attempt, and if so, what method was used and inquiring about depression and suicidal ideation in adolescents with asthma may be well worth the additional effort.
1. Runeson B, Tidemalm D, Dahlin M, et al. Method of attempted suicide as predictor of subsequent successful suicide: national long-term cohort study. BMJ. 2010;341:c3222.
2. Kuo CJ, Chen VC, Lee WC, et al. Asthma and suicide mortality in young people: a 12-year follow-up study. Am J Psychiatry. Published July 15, 2010. doi:10.1176/appi.ajp.2010.09101455.