Abstract and Figures

Unlabelled: Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. Suicidal crisis: Acute intervention should start immediately in order to keep the patient alive. Diagnosis: An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential. Treatment: Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. TREATMENT with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. TREATMENT with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT team: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. Family: The suicidal person independently of age should always be motivated to involve family in the treatment. Social support: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks. Safety: A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. Training of personnel: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.
Content may be subject to copyright.
Review
The
European
Psychiatric
Association
(EPA)
guidance
on
suicide
treatment
and
prevention
D.
Wasserman
a,
*,
Z.
Rihmer
b
,
D.
Rujescu
c
,
M.
Sarchiapone
d
,
M.
Sokolowski
a
,
D.
Titelman
a
,
G.
Zalsman
e,f
,
Z.
Zemishlany
e
,
V.
Carli
a
a
The
National
Centre
for
Suicide
Research
and
Prevention
of
Mental
Ill-Health
(NASP),
Karolinska
Institutet,
S-171
77,
Stockholm,
Sweden
b
Department
of
Clinical
and
Theoretical
Mental
Health
and
Department
of
Psychiatry
and
Psychotherapy,
Semmelweis
University,
Faculty
of
Medicine,
Budapest,
Hungary
c
Ludwig
Maximilians
University,
Munich,
Germany
d
Department
of
Health
Sciences,
University
of
Molise,
Campobasso,
Italy
e
Geha
Mental
Health
Centre,
Sackler
Faculty
of
Medicine,
Tel
Aviv
University,
Tel
Aviv,
Israel
f
Division
of
Molecular
Imaging
and
Neuropathology,
Psychiatry
Department,
Columbia
University,
New
York,
USA
European
Psychiatry
27
(2012)
129–141
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
11
April
2011
Received
in
revised
form
7
June
2011
Accepted
13
June
2011
Available
online
1
December
2011
Keywords:
Suicide
Depression
Psychiatric
diagnosis
Prevention
Identification
Treatment
A
B
S
T
R
A
C
T
Suicide
is
a
major
public
health
problem
in
the
WHO
European
Region
accounting
for
over
150,000
deaths
per
year.
Suicidal
crisis:
Acute
intervention
should
start
immediately
in
order
to
keep
the
patient
alive.
Diagnosis:
An
underlying
psychiatric
disorder
is
present
in
up
to
90%
of
people
who
completed
suicide.
Comorbidity
with
depression,
anxiety,
substance
abuse
and
personality
disorders
is
high.
In
order
to
achieve
successful
prevention
of
suicidality,
adequate
diagnostic
procedures
and
appropriate
treatment
for
the
underlying
disorder
are
essential.
Treatment:
Existing
evidence
supports
the
efficacy
of
pharmacological
treatment
and
cognitive
behavioural
therapy
(CBT)
in
preventing
suicidal
behaviour.
Some
other
psychological
treatments
are
promising,
but
the
supporting
evidence
is
currently
insufficient.
Studies
show
that
antidepressant
treatment
decreases
the
risk
for
suicidality
among
depressed
patients.
However,
the
risk
of
suicidal
behaviour
in
depressed
patients
treated
with
antidepressants
exists
during
the
first
10–14
days
of
treatment,
which
requires
careful
monitoring.
Short-term
supplementary
medication
with
anxiolytics
and
hypnotics
in
the
case
of
anxiety
and
insomnia
is
recommended.
Treatment
with
antidepressants
of
children
and
adolescents
should
only
be
given
under
supervision
of
a
specialist.
Long-term
treatment
with
lithium
has
been
shown
to
be
effective
in
preventing
both
suicide
and
attempted
suicide
in
patients
with
unipolar
and
bipolar
depression.
Treatment
with
clozapine
is
effective
in
reducing
suicidal
behaviour
in
patients
with
schizophrenia.
Other
atypical
antipsychotics
are
promising
but
more
evidence
is
required.
Treatment
team:
Multidisciplinary
treatment
teams
including
psychiatrist
and
other
professionals
such
as
psychologist,
social
worker,
and
occupational
therapist
are
always
preferable,
as
integration
of
pharmacological,
psychological
and
social
rehabilitation
is
recommended
especially
for
patients
with
chronic
suicidality.
Family:
The
suicidal
person
independently
of
age
should
always
be
motivated
to
involve
family
in
the
treatment.
Social
support:
Psychosocial
treatment
and
support
is
recommended,
as
the
majority
of
suicidal
patients
have
problems
with
relationships,
work,
school
and
lack
functioning
social
networks.
Safety:
A
secure
home,
public
and
hospital
environment,
without
access
to
suicidal
means
is
a
necessary
strategy
in
suicide
prevention.
Each
treatment
option,
prescription
of
medication
and
discharge
of
the
patient
from
hospital
should
be
carefully
evaluated
against
the
involved
risks.
Training
of
personnel:
Training
of
general
practitioners
(GPs)
is
effective
in
the
prevention
of
suicide.
It
improves
treatment
of
depression
and
anxiety,
quality
of
the
provided
care
and
attitudes
towards
suicide.
Continuous
training
including
discussions
about
ethical
and
legal
issues
is
necessary
for
psychiatrists
and
other
mental
health
professionals.
ß
2011
Elsevier
Masson
SAS.
All
rights
reserved.
*
Corresponding
author.
Tel.:
+46
8
52
48
49
37;
fax:
+46
8
52
48
77
93.
E-mail
address: danuta.wasserman@ki.se
(D.
Wasserman).
0924-9338/$
see
front
matter
ß
2011
Elsevier
Masson
SAS.
All
rights
reserved.
doi:10.1016/j.eurpsy.2011.06.003
1.
Epidemiology
of
suicide
1.1.
Suicide
in
the
world
According
to
the
World
Health
Organization
(WHO),
approxi-
mately
1
million
people
die
by
suicide
in
the
world
every
year
and
it
is
estimated
that
1.5
million
will
die
from
suicide
in
2020.
The
global
suicide
rate
is
14
suicides
per
100,000
inhabitants:
18
suicides
per
100,000
for
males
and
11
suicides
per
100,000
for
females.
The
global
suicide
rate
among
those
aged
75
years
is
approximately
three
times
higher
than
the
rate
among
youth
25
years
[160].
There
is
a
clear
predominance
of
male
over
female
suicides.
The
age
group
in
which
most
suicides
occur
is
35–44
years
for
both
genders.
Suicide
is
the
third
cause
of
death
among
adolescents
in
the
world;
however,
suicide
is
very
rare
before
puberty
[17,77].
1.2.
Suicide
and
attempted
suicide
in
the
WHO
European
Region
Information
from
the
WHO
on
mortality
due
to
suicide
for
the
WHO
European
is
presented
in
Table
1.
It
is
estimated
that
there
are
10–40
attempted
suicides
for
each
completed
suicide
[15].
This
ratio
is
higher
among
adolescents
and
decreases
with
age.
The
prevalence
of
lifetime
suicide
attempts
in
the
general
population
is
around
2.7
to
5.9%
[98,110,156].
According
to
the
latest
WHO
statistics
[160],
approximately
150,000
people
in
the
WHO
European
Region
completed
suicide
and
1,500,000
attempt
suicide.
The
highest
suicide
rates
for
both
males
and
females
are
found
in
Lithuania,
Russian
Federation,
Belarus,
Finland,
Hungary
and
Latvia.
However,
in
the
last
2–3
decades
several
countries
in
Europe
showed
a
marked
decline
in
their
suicide
mortality,
particularly
in
the
countries
with
high
suicide
rates
(e.g.,
Denmark,
Estonia,
Germany,
Hungary,
Sweden),
while
few
others,
primarily
those
with
relatively
low
suicide
rates,
showed
a
slightly
increasing
tendency
[115].
Suicide
usually
has
no
single
cause;
however,
up
to
90%
of
individuals
who
complete
suicide
meet
the
criteria
for
a
psychiatric
disorder,
such
as
mood
disorder,
substance
use
disorder,
psychosis
or
personality
dis-
orders
[10,28,52,83,114,140].
Comorbidity
of
depression
with
personality
and
anxiety
disorders
is
very
common
[28,52,137].
Attempted
suicide
is
the
most
important
predictor
of
a
completed
suicide
[143].
Prevention
of
attempted
suicide
and
suicide
through
adequate
diagnostic
procedures
and
treatment
of
those
disorders
is,
therefore,
a
high
priority
in
the
psychiatric
praxis.
Approximately
1,000,000
people
die
by
suicide
in
the
world
every
year.
Suicide
rates
are
higher
amongst
men
than
females.
The
age
group
in
which
most
suicides
occur
is
35–
44
years
for
both
genders.
It
is
estimated
that
there
are
10–40
attempted
suicides
for
each
completed
suicide
[15].
This
ratio
is
higher
among
adolescents
and
decreases
with
age.
Up
to
90%
of
individuals
who
complete
suicide
meet
the
criteria
for
a
psychiatric
disorder.
Comorbidity
with
psychiatric
disorders
is
high.
2.
Definition
A
meritorious
attempt
to
revise
the
nomenclature
for
the
study
of
suicide
was
performed
by
Silverman
[130,131].
Suicide
attempt
is
defined
as
a
self-inflicted,
potentially
injurious
behaviour
with
a
nonfatal
outcome
for
which
there
is
evidence
(either
explicit
or
implicit)
of
intent
to
die.
The
term
parasuicide
originated
in
Europe
and
covers
both
suicide
attempts
and
other
self-destructive
behaviour.
Deliberate
self-harm
(DSH)
is
defined
as
an
intentional
self-poisoning
or
self-injury,
irrespective
of
motivation
and
does
not
require
for
its
usage
the
establishment
of
suicidal
intent
[51].
3.
The
stress-vulnerability
model
and
the
suicidal
process
Suicidal
behaviour
can
be
conceptualized
as
a
complex
process,
which
develops
over
time.
It
can
range
from
suicidal
ideation,
which
can
be
communicated
through
verbal
or
non-verbal
means,
to
DSH,
suicide
attempt,
and,
in
some
cases,
completed
suicide.
The
suicidal
process
is
influenced
by
interacting
biological,
psycholo-
gical,
environmental
and
current
situational
factors.
One
of
the
most
important
components
modulating
the
risk
for
suicidal
behaviours
as
well
as
their
prevention
is
a
person’s
state
of
mental
health
and
self-image.
Many
people
who
suffer
from
mental
illness
of
various
types,
have
personality
disorders
and
have
undergone
terrible
life
events,
Table
1
Suicide
rates
(number
of
suicides
per
100,000
inhabitants)
in
the
European
region,
according
to
the
latest
WHO
mortality
data,
and
year
for
which
latest
data
are
available.
Country
Males
Females
Total
Year
Albania
6.31
3.45
4.84
2004
Andorra
Armenia
4.51
1.00
2.53
2006
Austria
26.1
8.20
12.69
2008
Azerbaijan
1.8
0.5
0.70
2007
Belarus
46.56
7.61
25.26
2007
Belgium
26.37
9.14
17.46
2004
Bosnia
Herzegovina
20.3
3.3
12.91
2007
Bulgaria
17.70
4.29
10.48
2006
Croatia
25.57
6.18
14.99
2008
Cyprus
3.43
0.96
2.13
2007
Czech
Republic
20.20
4.16
11.79
2008
Denmark
16.04
5.69
10.59
2006
Estonia
29.07
6.23
16.49
2008
Finland
28.96
8.27
18.45
2008
France
22.79
7.52
14.68
2007
Georgia
3.30
0.97
2.05
2001
Germany
15.46
4.68
9.80
2006
Greece
4.78
0.99
2.85
2008
Hungary
37.15
8.59
21.53
2008
Iceland
16.42
7.45
12.10
2008
Ireland
14.43
4.18
9.29
2008
Israel
7.88
1.68
4.65
2007
Italy
8.43
2.29
5.19
2007
Kazakhstan
44.92
9.25
25.69
2008
Kyrgyzstan
15.99
4.02
9.76
2006
Latvia
32.60
6.16
17.84
2007
Lithuania
55.93
9.10
30.72
2008
Luxembourg
19.71
7.37
13.07
2006
Macedonia
10.48
3.94
7.07
2003
Malta
5.35
1.03
3.13
2008
Netherlands
11.17
4.91
8.02
2008
Norway
14.00
6.09
10.02
2007
Poland
23.04
3.74
12.94
2007
Portugal
15.64
4.08
9.36
2003
Republic
of
Moldova
30.78
5.38
17.24
2008
Romania
18.37
3.55
10.63
2008
Russian
Federation
50.55
8.13
27.40
2006
San
Marino
7.28
0.00
3.62
2000
Serbia
22.17
7.97
14.62
2008
Slovakia
21.80
3.15
11.93
2005
Slovenia
28.75
6.64
17.19
2008
Spain
10.48
3.11
6.61
2005
Sweden
16.29
6.59
11.36
2007
Switzerland
21.85
9.11
15.12
2007
Tajikistan
Turkey
2.4
3.4
2.9
2005
Turkmenistan
Ukraine
36.51
5.66
19.54
2006
United
Kingdom
9.71
2.66
6.12
2007
Uzbekistan
8.87
2.37
5.53
2005
D.
Wasserman
et
al.
/
European
Psychiatry
27
(2012)
129–141
130
but
nonetheless
have
neither
considered
taking
their
own
lives
nor
committed
suicidal
acts.
The
propensity
to
suicide
has
interested
many
researchers
and
various
models
have
been
devised
to
explain
the
aetiology
of
suicidality.
In
the
stress-vulnerability
model
[89,149,152]
(Fig.
1),
genetic
make-up
as
well
as
acquired
susceptibility
contributes
to
a
person’s
predisposition
or
vulnera-
bility.
Early
traumatic
life
experiences,
chronic
illness
(especially
in
the
central
nervous
system
[CNS]),
chronic
alcohol
and
substance
abuse,
and
also
environmental
factors
such
as
social
position,
culture,
diet,
etc.
all
play
a
part
in
the
development
of
vulnerability.
Vulnerability
for
suicidal
behaviour
is
held
to
be
the
crucial
determinant
of
whether
or
not
it
is
manifested
under
the
impact
of
external
stressors.
The
vulnerability
towards
suicidal
behaviour,
in
certain
individuals,
involves
both
environmental
and
genetic
factors,
as
well
as
interactions
in-between
(GxE)
[73,153,154].
Suicidal
behaviours
cluster
into
families,
and
twin
and
adoption
studies
show
that
the
genetic
set-up
can
explain
up
to
50%
of
the
variance
in
suicidal
behaviour
[23].
Suicidal
behaviour
belongs
to
the
category
of
complex
diseases,
and
thus
involves
different
sets
of
interacting
gene
clusters,
active
at
different
time
points
during
the
life
span,
often
depending
on
the
presence
of
adverse
environmental
exposures,
and
this
results
in
a
probabilistic
rather
than
deterministic
genetic
diathesis,
which
can
catalyse
(rather
than
cause)
the
emergence
of
suicidal
behaviour
later
in
life
[153,154].
The
observed
pleiotrophy
of
certain
genes,
e.g.
the
serotonin
transporter
(SLC6A4)
and
monoamine
oxidase
(MAO)
genes,
which
play
a
role
in
both
the
developmental
stages
in
youth
as
well
as
in
adult
activity
of
the
same
circuits,
in
parallel
with
novel
hypotheses
concerning
modelling
plasticity,
in
addition
to
vulnerability,
may
help
to
resolve
certain
paradoxes
observed
in
relation
to
the
outcomes
of
treatment
with
Selective
Serotonin
Reuptake
Inhibitors
(SSRIs)
and
sometimes
contradictory
GxE
observations
[154].
Gene-environment
approach
gave
new
hope
for
possible
associations
especially
with
the
short
allele
(S)
of
the
serotonin
transporter
promoter
polymorphism
(5HTTLPR).
Caspi
et
al.
[27]
have
demonstrated
that
individuals
carrying
at
least
one
copy
of
the
S
allele
who
experienced
stressful
life
events
had
an
increase
in
depressive
symptoms
between
ages
21
and
26.
Furthermore,
life
events
occurring
after
age
21
predicted
depres-
sion
and
suicide
ideation
or
attempt
at
age
26
among
carriers
of
S
allele
who
did
not
have
a
prior
history
of
depression.
A
recent
meta-analysis
in
which
54
published
studies
were
included
and
analysis
were
stratified
by
the
type
of
stressor
studied,
showed
a
strong
evidence
for
an
association
between
the
S
allele
and
increased
stress
sensitivity
in
childhood
maltreatment
[70].
A
further
variation
in
the
serotonin
transporter
gene,
a
SNP
within
the
L
variant,
and
a
gene-by-environment
by
timing
interaction
model
were
suggested
to
be
involved
in
order
to
explain
the
findings
of
gene
environment
interactions
in
the
interplay
that
leads
to
suicidality
[165].
It
is
difficult
to
disentangle
genetic
effects
linked
solely
to
suicide
from
different
categories
of
psychiatric
disorders,
which
are
frequently
connected
with
suicidal
phenotypes.
Certain
severe
subtypes
of
psychiatric
diagnoses
reflect
genetic
risks,
e.g.
early
onset
depression
in
suicidal
behaviours
[88].
However,
some
suicides
also
occur
in
the
clinical
absence
of
psychiatric
disorders
and
it
is
important
to
note
that
genes
can
also
confer
susceptibility
that
can
only
be
detected
by
direct
biological
measurements
of
so-
called
functional
endophenotypes,
e.g.
measured
by
cortisol-levels
and
-response
or
functional
brain
imaging
[88].
Genetic
variants
which
contribute
to
various
types
of
susceptibility
to
mental
ill
health
and
suicidal
behaviour
are
continuously
being
found
and
investigated,
and
have
been
reviewed
in
detail
elsewhere
[153,154].
However,
any
complete
definition
of
a
genetic
diathesis
for
suicide
is
still
in
its
infancy.
Genetic
discoveries
can
become
particularly
relevant
for
treatment,
either
by
pointing
out
novel
molecular
drug
targets,
or
as
a
guide
to
understanding
the
response
of
available
treatments
(e.g.
pharmacogenomics)
[21].
Suicidal
behaviour
is
in
most
cases
the
final
outcome
of
a
process
that
is
influenced
by
the
interaction
of
genetic,
psy-
chological,
environmental
and
situational
factors.
The
stress-
vulnerability
model
is
widely
accepted
as
the
theoretical
framework
for
the
understanding
of
the
development
of
sui-
cidal
behaviour.
4.
Recognizing
the
patient
at
risk
for
suicide
4.1.
Suicide
in
different
clinical
settings
Suicidal
persons
in
most
cases
suffer
from
mental
disorders
or
psychiatric
symptoms
and
have
been
in
contact
with
general
practitioners
(GPs)
or
other
medical
services,
including
psychiatric
services,
shortly
before
the
completed
suicide
or
suicide
attempt.
Many
also
have
a
family
history
of
mental
disorders
and
suicidal
behaviour
[22,92].
Fig.
1.
The
suicidal
process
and
its
evolution
on
the
basis
of
the
individual
vulnerability.
From
D.
Wasserman,
C.
Wasserman.
Oxford
Textbook
of
Suicidology
and
Suicide
Prevention:
A
Global
Perspective
[155].
D.
Wasserman
et
al.
/
European
Psychiatry
27
(2012)
129–141
131
Population-based
mortality
studies
in
psychiatric
care
show
a
16-fold
risk
for
suicide
among
psychiatric
inpatients
and
a
2–3-fold
greater
risk
for
outpatients
compared
to
the
risk
of
patients
treated
for
psychiatric
problems
in
primary
care
[76].
Among
patients
who
committed
suicide
and
who
had
been
in
contact
with
mental
health
services,
the
following
major
diagnostic
categories
amongst
cases
of
suicide
were
observed:
mood
disorders,
schizophrenia,
personality
disorders
and
substance
use
disorders
[63,76].
It
has
been
reported
that
approximately
24%
of
people
who
complete
suicide
had
been
in
contact
with
mental
health
services
in
the
year
before
their
death.
A
quarter
of
them
committed
suicide
within
3
months
after
hospital
discharge,
with
a
peak
in
the
first
week,
and
the
highest
number
of
suicides
occurring
the
day
after
discharge
[9].
These
data
demonstrate
a
key
role
for
the
management
of
mental
disorders
in
suicide
prevention.
If
one
considers
treatment
effectiveness
of
major
mental
disorders
to
be
50%,
and
assumes
that
50%
of
people
are
correctly
diagnosed
and
successfully
treated,
one
could
expect
a
reduction
in
the
suicide
rate
of
around
20%
[16].
This
goal
is
possible
to
reach,
by
using
a
comprehensive
suicide
preventive
strategy,
with
appropriate
treatment,
adequate
follow-up
and
rehabilitation
services
for
people
with
mental
disorders,
especially
those
suffering
from
mood
disorders,
schizophrenia
and
substance
use
disorders.
Suicide
is
almost
always
associated
with
the
presence
of
an
underlying
psychiatric
disorder.
Approximately
half
of
people
who
complete
suicide
had
been
in
contact
with
health
care
services
shortly
beforehand.
Risk
of
suicide
is
high
up
to
3
months
after
discharge
from
a
psychiatric
hospital,
with
the
highest
number
of
suicides
within
the
first
week
after
leaving
the
hospital.
5.
Risk
factors
for
suicide
5.1.
Heritability
Suicidal
behaviours
aggregate
in
families
and
it
seems
that
they
are
inherited
independently
of
mental
disorders
[22,23,92].
Twin
data
also
confirm
heritability
of
suicide
[120,121].
Family
history
of
suicidal
behaviour
is
an
independent,
non-interacting
risk
factor
for
attempting
suicide
[119].
5.2.
Current
and
lifetime
psychiatric
disorders
The
suicide
risk
in
patients
with
mood
disorders
has
been
estimated
to
be
13–26
times
as
high
as
that
in
the
general
population
[8,49];
in
schizophrenia,
8.5–10
times
higher
[49,57]
and
in
alcohol
and
other
substance
use
disorders
it
is
six
times
higher
[49].
A
study
from
Denmark
on
a
prospective
cohort
of
over
176
thousand
subjects
estimated
that
absolute
risk
for
completed
suicide
after
first
hospital
contact
due
to
mental
disorder
was
7.8%
for
bipolar
disorder,
6.7%
for
unipolar
affective
disorders
and
6.5%
for
schizophrenia
[99].
The
diagnostic
panorama
of
mental
disorders
in
attempted
suicides
has
a
similar
pattern
to
that
of
completed
suicide.
Most
frequently
depressive,
substance
use
and
comorbid
personality
disorders
are
present
[10,140].
Clinical
studies
show
that
successful
treatment
reduces
the
risk
of
suicidal
behaviour
in
patients
with
various
psychiatric
disorders
[83].
5.2.1.
Major
depression
Depression
in
patients
who
complete
suicide
is
usually
severe,
and
accompanied
by
insomnia,
agitation,
anxiety,
appetite
and
weight
loss,
severe
hopelessness,
incongruent
feelings
of
heavy
guilt,
worthlessness,
thoughts
of
death
and
recurrent
suicidal
ideation
not
divertible
by
external
interaction.
Impulsive
and
aggressive
behaviour,
along
with
cluster
B
personality
disorders,
alcohol/drug
abuse
and
dependence
increases
the
risk
of
suicide
in
people
with
major
depression
[8,49,114].
Mood
disorders
signifi-
cantly
increase
the
risk
of
suicidal
behaviours
in
adolescence
[24,72].
5.2.2.
Bipolar
disorders
Suicide
mortality
of
people
with
bipolar
disorder
is
high,
approximately
25
times
higher
than
the
general
population.
Suicidal
behaviour
is
particularly
high
in
patients
showing
rapid
cycling
course,
in
mixed/agitated
depression,
in
patients
with
early
onset
of
illness,
and
during
the
first
years
after
the
first
diagnosis
[26].
Comorbidity
in
bipolar
disorders
is
high
especially
with
anxiety
disorders
and
with
the
abuse
of
alcohol
and
drugs
[3,10,49,114].
5.2.3.
Anxiety
disorders
Anxiety
disorders,
especially
in
adolescents
and
young
adult-
hood,
are
associated
with
lifetime
suicidal
ideation
and
suicide
attempts,
[20].
There
is
a
high
co-morbidity
of
anxiety
disorders
in
suicidal
adults,
particularly
with
major
depression
and
substance
abuse.
Severe
anxiety
may
be
a
critical
causal
factor
of
acute
suicidality
[36,82].
Fawcett
[35]
in
his
early
work
showed
that
anxiety
disorders
are
highly
under-recognized
and
under-treated
in
suicidal
people.
In
post-traumatic
stress
disorders,
suicidality
is
associated
with
co-morbidity
of
depression
and
substance
abuse
[103].
The
qualitative
studies
of
single
cases
[144]
as
well
as
personal
accounts
written
by
individuals
near
to
suicide
[5,68]
illustrate
the
role
in
suicidality
of
severe
anxiety
and
anxiety-
fraught
depressive
states,
bordering
to
annihilation
anxiety
[85].
5.2.4.
Alcohol
and
other
substance
use
disorders
All
substance
use
disorders
increase
the
risk
of
suicide.
The
relationship
between
alcohol
and
suicidal
behaviour
is
complex,
as
alcohol
has
short-term
positive
effects
on
the
alleviation
of
despondency.
As
an
intoxicating
substance,
alcohol,
in
the
long
run
impairs
cognitive
processes,
increases
impulsivity
and
aggression,
and
lowers
the
threshold
for
triggers
of
suicidal
behaviour.
Suicide
victims
who
suffer
from
alcohol
and
other
substance
use
disorders
are
often
younger,
male,
divorced
or
separated.
They
often
suffer
from
recent
adverse
life
events,
and
they
are
also
likely
to
be
intoxicated
at
the
time
of
the
suicide
[107].
Therefore,
in
the
clinical
practice,
recent
and
accumulated
negative
life
events
and
deterioration
of
social
situation,
both
at
work
and
in
other
contexts
should
be
monitored
in
the
alcohol-
and
drug
dependent
patients.
5.2.5.
Schizophrenia
The
increased
risk
of
suicide
in
schizophrenic
patients
is
associated
with
previous
depressive
disorders,
substance
misuse
or
dependence,
previous
suicide
attempts,
agitation
and
motor
restlessness,
fear
of
mental
disintegration,
poor
adherence
to
treatment
and
recent
loss
events
[54].
Schizophrenic
patients
living
alone
are
at
greater
risk
of
suicide.
Suicide
risk
seems
to
be
related
to
affective
symptoms
and
less
to
core
psychotic
symptoms
[54].
The
majority
of
schizophrenic
patients
who
commit
suicide,
do
so
after
their
first
episode,
while
suffering
depressive
symptoms.
While
suicide
risk
in
schizophrenia
is
higher
among
young
people
[102],
relatively
few
studies
have
investigated
suicidality
in
adolescents
with
schizophrenia.
First-episode
psychosis
is
considered
to
be
a
critically
important
time
for
intervention
in
the
course
of
schizophrenia.
A
study
on
a
prospective
cohort
of
individuals
with
first-episode
psychosis
reported
that
21.6%
of
the
patients
attempted
suicide
and
4.3%
completed
suicide
during
the
7-year
follow-up
period
[116].
In
another
study,
suicide
risk
has
been
found
to
be
highest
in
the
first
month
of
treatment,
decreasing
rapidly
over
the
following
D.
Wasserman
et
al.
/
European
Psychiatry
27
(2012)
129–141
132
6
months
and
declining
slightly
thereafter
[37].
Studies
found
violent
and
suicidal
behaviour
to
be
common
in
psychotic
adolescents
[12,65].
Data
is
still
relatively
poor
regarding
its
proper
management,
particularly
in
adolescent-onset
cases.
5.2.6.
Eating
disorders
Overall,
mortality
by
suicide
has
been
found
to
be
increased
in
patients
with
eating
disorders
[29,60].
The
risk
factors
for
attempted
suicide
and
suicide
in
eating
disorders
are
associated
with
depression,
social
phobia
and
obsessive-compulsive
symp-
toms.
One
of
the
strongest
predictors
of
suicide
among
persons
with
eating
disorders
is
comorbidity
with
alcohol
abuse
[72].
5.3.
Trauma
Traumas,
especially
different
kinds
of
physical
violence,
mental
and
sexual
abuse
both
in
childhood
and
adulthood,
bullying,
victimization
and
exclusion
at
school
or
in
the
work
place,
are
significant
risk
factors
for
suicide.
There
is
strong
evidence
from
population-based
studies
that
childhood
trauma
is
a
risk
factor
for
suicidal
behaviour
[95,97,125,126].
A
review
of
clinical
studies
also
concluded
that
patients
who
have
experienced
childhood
trauma
are
more
vulnerable
to
later
social
stress
or
adversity
and
are
prone
to
suicidal
behaviour
[124].
5.4.
Stressful
life
events
(SLEs)
Negative
life
events
such
as
loss,
change
in
life
situation,
and
different
narcissistic
injuries
can
act
both
as
a
catalyst
and
as
a
factor,
which
precipitates
the
development
of
the
suicidal
process.
Traumatic
loss
includes
not
only
death
of,
or
separation
from
a
partner,
friend
or
a
significant
other;
but
also
a
loss
of
a
national
or
cultural
affiliation;
loss
of
health;
loss
of
possessions
or
autonomy
due
to
hospitalization;
loss
of
employment;
study
opportunities;
home
or
financial
position.
Important
transitions
or
changes
in
life
situations
such
as:
entering
or
leaving
periods
of
development,
e.g.
puberty,
middle
age,
the
menopause,
or
old
age,
can
be
a
risk
situation
for
vulnerable
individuals
[150].
Immigrants
from
countries
with
high
number
of
suicides,
or
immigrants
from
other
cultures,
e.g.
Islamic
population
in
Europe,
show
higher
risk
for
attempted
suicide
than
the
native
population
[25].
Exposure
to
completed
or
attempted
suicide
is
also
an
important
risk
factor
especially
in
young
people
[43].
Between
1
and
5%
of
adolescent
suicides
have
been
reported
to
occur
in
clusters
[44].
Contagion
of
suicidal
behaviour
among
adolescents
has
also
been
reported
to
occur
during
hospitalization
[142].
The
US
Centre
for
Disease
Control
issued
specific
guidelines
to
prevent
the
phenomenon
of
suicide
clustering
in
the
community
[100].
Unsolved
relationship
problems,
family
violence,
particularly
childhood
physical
and
sexual
abuse,
insecure
sexual
orientation,
especially
in
adolescence
and
young
adults,
increase
the
risk
of
attempted
suicide
and
suicide
in
those
with
vulnerable
personal-
ities.
Breaking
the
law,
being
imprisoned
and
circumstances
related
to
public
holidays
are
also
risk
situations
[151].
Seasonal
patterns,
with
more
suicides
in
the
spring
and
summer
than
during
the
winter
have
also
been
observed
[112].
Suicide
may
take
place
in
association
with
a
day
of
particular
significance
to
the
person
involved,
for
example,
it
can
coincide
with
the
same
date
when
a
family
member
committed
suicide,
or
occur
in
connection
with
anniversaries,
days
or
events
that
are
negatively
emotionally
charged
for
the
individual.
5.5.
Chronic
illness
Significant
correlations
between
suicidal
behaviour
have
been
reported
with
diseases
in
the
CNS
such
as
multiple
sclerosis,
Huntington’s
chorea,
epilepsy,
Parkinson’s
disease,
migraine,
brain
and
spinal
cord
lesions,
as
well
as
in
patients
with
stroke,
certain
forms
of
cancer,
diabetes,
and
chronic
pain
[138].
Findings
are
robust
for
increased
risk
of
suicide
in
neurological
disorders
and
cancer.
Studies
in
cardiac,
lung
and
other
somatic
disorders
are
fewer
and
the
results
are
not
conclusive.
In
children
and
adolescents,
as
in
adults,
other
physical
disorders
associated
with
elevated
suicide
risk
are:
new
onset
diabetes
mellitus,
bronchial
asthma,
HIV,
epilepsy
and
multiple
sclerosis
[166].
5.6.
Protective
factors
Cognitive
flexibility;
active
coping
strategies
that
help
to
find
alternative
solutions
to
difficult
life
situations;
healthy
lifestyles
characterized
by
socializing
with
the
people
who
do
not
use
drugs
and
misuse
alcohol;
keeping
a
good
diet;
good
sleeping
patterns;
physical
exercise
and
an
active
life,
are
important
protective
factors
that
can
be
stimulated
both
by
clinical
and
community
activities.
Strengthening
the
sense
of
personal
value;
confidence
in
oneself
and
one’s
situation;
seeking
help
and
advice
when
difficulties
arise
and
important
choices
must
be
made;
supporting
training
in
communication
skills,
can
all
be
facilitated
by
different
kinds
of
group
activities
with
patients
both
at
the
clinic
or
in
the
community
[149].
The
clinic’s
collaboration
with
the
community
services,
concerning
integration
into
ordinary
life
of
the
suicidal
patient
through
work,
and
other
activities
are
important
measures
for
suicide
prevention
that
can
be
developed
in
collaboration
between
psychiatric
clinics
and
proactive
psychiatric
rehabilita-
tion
and
social
services
at
the
community
level.
It
has
been
also
found
that
besides
good
family
and
social
support,
practicing
a
religion
as
well
as
having
a
high
number
of
children
has
a
protective
role
against
suicidal
behaviour
[39].
Interaction
of
risk
and
protective
factors
determine
the
vulner-
ability
of
an
individual
to
develop
suicidal
behaviour.
Several
risk
factors
have
been
studied
and
were
found
to
be
signifi-
cantly
associated
with
suicide.
Suicide
risk
factors
are
cumu-
lative
in
their
nature;
the
higher
the
number,
the
higher
the
probability
is
of
suicidal
behaviour.
A
thorough
evaluation
of
risk
and
protective
factors
should
be
performed
for
every
patient
at
risk
for
suicide.
6.
Assessment
of
the
suicidal
patient
The
suicidal
risk
assessment
should
always
be
comprehensive
and
include
psychiatric,
somatic,
psychological
and
social
per-
spectives.
Neurobiological
assessment
can
be
performed
in
specialized
settings.
As
suicide
risk
fluctuates
within
a
short
period
of
time,
it
is
important
to
repeat
the
suicide
risk
assessment
over
time
in
an
empathic
and
not
mechanistic
way.
A
suicidal
person
frequently
reacts
to
negative
life
events
with
shame
and
irrational
guilt
feelings,
despair,
hopelessness,
as
well
as
with
anger
and
rage.
Their
propensity
to
provoke
repetitive
emotional
injury
or
offence,
thus
confirming
the
idea
that
they
are
neither
needed
nor
loved
by
others,
may
nourish
fantasies
of
revenge
and
lead
to
uncontrolled
outbursts
and
self-destructive
acts.
To
others
such
behaviour
may
seem
paradoxical:
despite
a
great
need
for
help
and
support
from
health
care
staff
and
significant
others,
a
suicidal
person,
like
the
person
with
a
severe
personality
disorder,
often
fears
dependency
and
intimacy,
and
devalues
both
the
need
for
closeness
and
attachment
to
significant
others
[75].
Thus,
the
suicidal
person
may
mislead
both
family
members
and
hospital
staff,
giving
an
unrealistic
sense
of
independence
and
of
being
able
to
manage
without
the
help
of
others.
Similarly
misleading
can
be
the
signs
of
tranquillity
once
a
decision
is
taken
to
carry
out
a
suicide,
which
may
paradoxically
D.
Wasserman
et
al.
/
European
Psychiatry
27
(2012)
129–141
133
install
a
momentary
composure
and
a
release
from
internal
tension.
Although
extreme
ambivalence
to
living
or
dying
is
often
strongly
expressed
by
the
suicidal
individual,
it
can
be
missed
by
others.
If
observed
in
the
diagnostic
and
treatment
process,
dialogue
and
reflection
on
such
ambivalence
can
be
used
to
motivate
the
patient
for
treatment,
arrest
the
negative
develop-
ment
of
the
suicidal
process,
and
prevent
suicide.
If
ambivalence
and
suicidal
communication
goes
undiscovered,
the
treatment
process
and
the
life
of
the
patient
can
be
endangered
[85,86,151].
6.1.
Suicidal
communication
It
sometimes
happen
that
suicide
attempters
who
are
treated
at
the
clinic
are
evaluated
from
all
possible
points
of
view,
without
exploratory
questions
about
the
attempted
suicide
being
posed.
Such
omissions
can
contribute
to
the
patient’s
feelings
of
guilt,
shame,
and
helplessness.
Suicidal
intentions
can
be
explicitly
and
directly
expressed,
in
the
clinical
situation,
but
indirect
suicidal
communication
is
also
common.
This
communication
is
not
always
easily
intelligible
and
may
be
missed
by
the
clinician
if
he
or
she
does
not
know
the
patient
well
and
cannot
place
what
is
said
within
its
context.
Non-verbal
communication
or
acting
out,
like
the
acquisi-
tion
of
a
weapon,
the
collection
of
prescription
medicines,
writing
a
will,
giving
away
keepsakes
and
at
the
same
time
seeking
solitude
or
avoiding
health
care
services,
should
ideally
be
reported
by
relatives
or
friends,
but
it
is
up
to
the
medical
staff
to
ask
for
such
information.
The
suicidal
person’s
own
capacity
to
ask
for
and
accept
help
is
often
poor.
Some
suicidal
people,
even
those
who
are
married
or
live
with
a
partner,
can
tend
not
to
share
their
thoughts
with
others.
Moreover,
suicidal
communication
evokes
many
different
responses
from
others,
including
the
health
care
staff.
It
can
evoke
empathy
but
also
ambivalence
and
frustration,
especially
if
the
patient
is
demanding,
blaming,
aggressive,
and
noncompliant
with
the
treatment
regi-
mens
and
the
helpful
intentions
of
both
relatives
and
the
clinical
staff
[86,157,158].
Such
reactions
can
be
difficult
to
deal
with
constructively
and
it
is
advisable
to
train
staff
on
a
regular
basis
about
how
to
manage
strong
emotional
reactions
as
well
as
how
to
recognize
suicidal
risk
situations.
Consultations
with
other
collea-
gues
and
the
opportunity
for
reflection
and
supervision
should
be
an
integrated
part
of
the
work
routines
in
the
psychiatric
workplace.
6.2.
Previous
history
of
suicidal
behaviours
A
suicide
attempt
is
by
far
the
strongest
predictor
for
a
completed
suicide
[143].
Previous
history
of
suicidal
behaviour,
both
on
the
individual
and
on
the
family
level
should
always
be
collected.
6.3.
Family
history
of
suicide
and
attempted
suicide
Data
concerning
familial
history
of
suicide
and
strongly
related
disorders,
such
as
depression
and
substance
abuse,
can
help
in
the
evaluation
of
the
patient’s
risk
for
suicide.
Usually,
the
collection
of
data
concerning
familial
history
of
suicidal
behaviours
and
mental
disorders
is
based
on
the
report
by
the
patient
only.
A
standardized
method
of
investigation
using
for
example
the
Family
History
Questionnaire,
may
lead
to
a
reduction
of
the
risk
of
under-
reporting
[6].
6.4.
Assessment
of
underlying
psychiatric
disorders:
DSM-IV
axis
I
diagnoses
A
clinical
diagnostic
interview
can
be
performed,
according
to
the
classification
system
used
in
the
clinic,
e.g.
ICD
10
[161]
or
DSM-IV-TR
[4].
The
DSM-IV-TR
system
is
recommended
in
suicide
risk
assessment
as
it
is
a
multiaxial
diagnostic
system
and
therefore
useful
in
the
diagnostic
process
as
suicidal
persons
often
suffer
from
co-morbid
conditions,
both
on
the
same
axis,
and
between
different
axes,
and
this
can
be
elucidated
in
a
systematic
way
when
following
all
of
the
DSM-IV-TR
axes.
It
has
been
proposed
that
suicidal
behaviour
could
be
considered
as
a
separate
diagnostic
category
in
the
next
version
of
the
DSM
(DSM-V)
[101].
6.5.
Assessment
of
personality
disorders:
DSM-IV
axis
II
diagnoses
According
to
different
studies,
44–62%
of
suicide
attempters
meet
the
diagnostic
criteria
for
personality
disorders
[28].
Impulsive,
aggressive,
pessimistic
personality
features,
as
well
as
cyclothymic
and
irritable
affective
temperaments
increase
the
risk
of
suicidal
behaviour
in
patients
with
any
DSM-IV
Axis
I
disorder.
Borderline
personality
disorder
(BPD),
anti-social
personality
disorder
and
avoidant
personality
disorder
increase
the
risk
for
suicide,
particularly
in
the
case
of
comorbid
major
depressive
episodes
or
substance
use
disorders
[31].
Previous
studies
have
reported
poor
reliability
for
detecting
personality
disorders,
probably
due
to
unstructured
instruments
that
were
used.
Structured
Clinical
Interview
for
DSM
disorders
axis
II
personality
disorders
(SCID-2)
shows
good
psychometric
prop-
erties.
Using
this
instrument,
inter-rater
reliability
for
person-
ality
disorders
performed
by
trained
senior
clinicians
is
good
[127].
In
a
population
of
adolescents
who
had
completed
suicide,
it
was
found
that
around
43%
had
a
diagnosis
of
conduct
disorder
or
anti-social
personality
disorder
[90].
A
history
of
childhood
abuse
and
post-traumatic
stress
disorder,
in
people
with
BPD
increases
the
risk
for
suicidal
behaviour
[133].
Studies
also
implicate
that
perceived
negative
life
events,
especially
involving
interpersonal
distress,
loss
and
legal
problems,
are
more
likely
to
precipitate
suicidal
behaviour
in
people
who
have
a
pre-existing
personality
disorder
[56,61,62,163].
During
the
previous
6
months
before
suicidal
acts,
an
increase
in
the
number
of
negative
life
events,
particularly
in
the
month
before
the
suicide
attempt,
has
been
observed
in
people
with
personality
disorders.
Characteristics
of
people
with
personality
disorders
such
as
poor
coping
strategies,
impulsivity,
erratic
behaviour,
aggressive
behaviour
and
hostility
[137],
anxiety
and
primitive
psychological
defences
[145]
are
all
associated
with
suicide
and
self-destructive
behaviours.
Examples
of
primitive
defence
strategies
are
the
illusion
of
being
self-sufficient,
paranoid
projections
that
depict
others
as
all-bad
and
persecut-
ing,
aggressive
attacks
on
one’s
self
and
others
[58,85].
Cognitive
impairment,
resulting
in
deficits
in
thinking
about
the
future,
are
associated
with
suicidality
both
in
antisocial
personality
disorder
and
BPD
[84].
Major
factors
for
suicide
are
the
co-
occurrence
of
axis
I
and
II
diagnoses.
People
with
co-morbidity
disorders
are
more
likely
to
have
made
more
previous
suicide
attempts
[52].
Not
being
able
to
make
friends,
having
an
addiction
as
well
as
depression,
feelings
of
hopelessness,
aggressive
and
impulsive
behaviours
are
found
in
the
co-morbid
groups.
6.6.
Somatic
disorders:
axis
III
disorders
Severe
somatic
disorders,
especially
in
the
CNS
but
also
disorders
that
imply
pain,
physical
disability
and
distress,
increase
the
risk
for
suicide.
Depression
and
anxiety,
cognitive
deficits,
medical
induced
abuse
of
medication
due
to
pain
influences
the
risk
of
suicide.
The
time
before
and
days
after
a
serious
somatic
diagnosis,
is
given
is
a
risk
period,
as
is
the
case
if
the
patient
has
had
the
disease
for
a
long
time
and
their
status
deteriorates
[138].
D.
Wasserman
et
al.
/
European
Psychiatry
27
(2012)
129–141
134
The
assessment
of
a
suicidal
patient
should
always
include
an
evaluation
of
the
underlying
psychiatric,
personality
and
so-
matic
disorders,
the
evaluation
of
past
history
of
suicidal
behaviour
in
the
patient
and
his
family,
and
the
presence
of
explicit
and
implicit
suicidal