BH Lecture 13: Suicide and Homocide

What are the three categories of stress causes?

Routine stress (work, school, family, finances), stress from negative change (job loss, divorce, death, illness), and traumatic stress (war, assault, major accident, natural disaster, pandemic)

What is coping?

The thoughts and behaviors mobilized to manage internal and external stressful situations — conscious and voluntary responses, consistent over time and across situations

How do coping mechanisms differ from defense mechanisms?

Coping mechanisms are conscious and voluntary, whereas defense mechanisms are subconscious/unconscious responses

What is reactive vs proactive coping?

Reactive coping is a reaction following a stressor (reactive individuals perform better in a variable environment); proactive coping aims to neutralize future stressors (proactive individuals perform better in a stable environment)

What are the four categories of coping?

Problem-focused, emotion-focused, meaning-focused, and social coping

What is problem-focused coping?

Addressing the problem causing distress (active coping, planning, restraint) — often associated with favorable outcomes, particularly if the stressor is controllable

What is emotion-focused coping?

Aiming to reduce the negative emotions associated with the problem (positive reframing, acceptance, humor, turning to religion)

What is meaning-focused coping?

Using cognitive strategies to derive and manage the meaning of the situation (reordering priorities, infusing positive meaning, rethinking goals)

What is social coping?

Seeking emotional or instrumental social/community support

What is maladaptive coping?

Coping mechanisms associated with poor mental health outcomes and higher psychopathology (e.g., disengagement, avoidance, emotional suppression)

What are the concerns associated with maladaptive coping?

Health-risk behaviors, less treatment adherence, more alcohol/cigarette use, viewing providers as unsupportive, psychiatric disorders (PTSD, MDD, GAD, somatic disorder), and HTN/heart disease

What factors influence how patients respond to physical symptoms?

Past experience with illness, personality/coping styles, familial and cultural norms, interpersonal interactions, and symptom perception/attachment of meaning

How can assigning meaning to symptoms affect a patient?

It can help them feel in control (pain may decrease if they believe they can control it), and may positively or negatively impact self-esteem

Is observed pain expression a good indicator of pain severity?

No — pain behaviors vary by personality, culture, prior experience, and context; observed expression shouldn't be used alone to infer severity or credibility

Does the absence of a diagnosis mean absence of abnormalities?

No — absence of a diagnosis does not equal absence of abnormalities or dysfunction; severe illness and suffering may still exist

What is 'overuse syndrome' in the context of coping?

Attempts to maintain normalcy that may result in overuse (whereas guarding an injured shoulder may lead to frozen shoulder)

What is caregiver stress?

The emotional and physical strain of providing care — caregivers report much higher levels of stress and many are 'on call' almost all day

What are signs and symptoms of caregiver stress?

Feeling overwhelmed/alone, sleeping too much or too little, weight changes, tiredness, anhedonia/sadness/worry, and somatic symptoms (headache, myalgia)

What are the health effects of caregiver stress?

Depression/anxiety (more in women), weakened immune system, obesity, increased risk of chronic disease, and short-term memory/attention impairment (especially caregivers of Alzheimer's spouses)

What communication style is associated with less pain interference and distress?

Assertive communication — expressing needs clearly/respectfully while acknowledging other perspectives (a balance between passivity and aggression)

What do patients and families expect from providers?

To be supportive, accessible, understanding, knowledgeable, kind, and empathetic — maintaining open, honest, empathetic dialogue

What is the analogy for suicide in psychiatry?

'Suicide is to the Psychiatrist what cancer is to the Internist'

What is suicidal ideation?

Thoughts about suicide that exist on a spectrum and do not necessarily include a plan or intent to act

What is passive suicidal ideation?

A desire to be dead or not exist, without active thoughts of causing one's own death (e.g., 'I wish I could go to sleep and not wake up')

What is active suicidal ideation?

Thoughts of taking action to kill oneself, with or without a specific method, plan, or intent (e.g., 'I've been thinking about killing myself')

How common was suicidal ideation among US adults in 2024?

An estimated 14.3 million seriously considered suicide, 4.6 million made a plan, and 2.2 million attempted suicide

What percentage of high school students seriously considered suicide (2023 data)?

20.4%

What are warning signs of suicidal ideation?

Expressing hopelessness or being a burden, talking about wanting to die/hurt oneself, withdrawing from friends/activities, unusual anger/rage, and giving away prized possessions

What is suicidal intent?

The degree to which a patient desires, expects, or intends to act on suicidal thoughts with the purpose of causing their own death

How must suicidal intent be assessed?

Directly, rather than inferred from risk factors alone (it may be present with or without a plan and can change rapidly)

What is the key distinction between ideation, plan, and intent?

Ideation = thoughts; Plan = method/place/timing/prep; Intent = desire/expectation to act

What are preparatory behaviors and acute warning signs of suicidal intent?

Writing a will, putting affairs in order, giving away possessions, expressing peace/calm after making plans, increased drug/alcohol use, saying goodbye, and collecting pills or buying a weapon

Can suicide be predicted with certainty?

No — suicide cannot be predicted with certainty in any individual; the absence of warning signs does not establish safety

How many suicide deaths occurred in the US in 2024, and how many per day?

48,824 suicide deaths (133 deaths per day)

Where does suicide rank as a cause of death in the US?

The 10th overall cause of death

How does suicide risk differ by gender?

The suicide death rate among males is nearly 4x that of females — men are 50% of the population but 80% of all suicide deaths

Which age group had the highest suicide rates in 2024?

People ages 80+ (older adults attempt less often but have higher death rates)

For which ages is suicide the 2nd leading cause of death?

Ages 10-14 and 25-34 (3rd leading for 15-24, 4th for 35-44)

What is the leading method of suicide?

Firearms (remained the leading method in 2024)

What percentage of suicide cases had suspected alcohol use at time of death?

Roughly 15%

What is one of the STRONGEST established risk factors for future suicidal behavior?

Previous suicidal behavior — risk is particularly elevated following a recent attempt and after discharge from acute psychiatric care

What relationship/social factors affect suicide risk?

Relationship conflict, separation, or loss and social isolation increase risk; strong connections with family, friends, and community are protective

Which occupations demonstrate higher suicide rates?

Physicians/clinicians, construction, and farming, among others

What is the genetic contribution to suicide?

It tends to run in families; family history of suicide increases risk (supported by twin and adoption studies)

Can a single neurotransmitter or biomarker predict suicide?

No — suicide is multifactorial and no single neurotransmitter or biomarker can clinically predict it

What are protective factors against suicide?

Reasons for living, effective coping/problem-solving skills, supportive social connections, connection to community, healthcare engagement, and reduced access to lethal means

What is the key principle when asking about suicide?

ALWAYS ask about suicidal feelings and behaviors, and be direct — it's not enough to ask if they are suicidal

What should a medical assessment of the suicidal patient include?

Vitals, intoxication/withdrawal, toxidromes, delirium, trauma/self-injury, neurologic abnormalities, and other organic medical issues

What does the SAFE-T assessment stand for?

Suicide Assessment Five-Step Evaluation and Triage

When should urgent psychiatric evaluation/hospitalization be considered for a suicidal patient?

Current suicidal intent, a specific plan with access to lethal means, a recent attempt or preparatory behavior, severe agitation/psychosis/mania, inability to maintain safety, or an unsafe environment

When may outpatient management be appropriate for a suicidal patient?

No current intent, no recent behavior/preparatory acts, ability to participate in a safety plan, reducible lethal-means access, reliable follow-up, and sufficient protective factors

Does a suicide plan automatically mandate hospitalization?

No — a suicide plan does not automatically mandate hospitalization, and the absence of a plan does not establish safety

What is the Baker Act's role in suicidal patients, and who can initiate it in Florida?

Involuntary psychiatric hospitalization when statutory criteria are met; PAs may initiate a Baker Act in Florida

What are the key components of outpatient suicide management?

Collaborative safety planning, lethal-means safety, clear crisis instructions, and timely follow-up/warm handoff

What FDA warning applies to antidepressants and suicide?

Increased suicidal thoughts/behavior in pediatric and young adult patients — monitor for worsening symptoms after starting/changing therapy

Why should a dramatic clinical change in a suicidal patient raise suspicion?

Patients recovering from a suicidal depression are at risk, and a sudden improvement may be suspicious

What is the 988 resource?

The Suicide & Crisis Lifeline — call or text 988 (Crisis Text Line: text HOME to 741741)

Are all suicides preventable?

No — 21.4% occur in patients already receiving psychiatric treatment, and some die despite the best care available

What is the National Strategy for Suicide Prevention (2024)?

A new 10-year comprehensive approach under HHS with goals to prevent suicide, support at-risk people, promote recovery, and support survivors of suicide loss

Who are the often-forgotten survivors of suicide loss?

Clinicians who have lost patients (also children who lost parents feel abandonment, and parents who lost children feel failed responsibility)

What complicated grief responses can suicide bereavement involve?

Guilt, anger, shame, perceived responsibility, and unanswered questions

How many homicide deaths occurred in the US in 2024?

20,162 homicide deaths (5.9 per 100,000); homicide mortality has declined from the earlier 2020s

What proportion of homicide deaths involve firearms?

Approximately 3 out of 4 (15,364 firearm homicide deaths in 2024)

For which age group is homicide a leading cause of death?

Adolescents and young adults — among the leading causes for ages 15-19

What factors are associated with homicide?

Domestic/intimate partner violence (especially of women), gang violence, and population-level factors (socioeconomic disadvantage, firearm/alcohol availability)

What are the four categories of homicidal behavior risk factors?

Individual, relationship, community, and societal

What are individual risk factors for homicidal behavior?

History of violence/abuse, escalating violence, substance use, access to weapons (firearms in the home), obsessive behavior/stalking, and acute psychosis

What relationship factors increase homicide risk?

Domestic violence (stalking, coercive behavior, separation), threats with a weapon or to harm the victim/children, jealousy, controlling behaviors, estrangement, and abuse during pregnancy

What information is gathered during a homicidal risk evaluation?

Specific target, expressed threat, intent, plan, timeframe, weapon/means access, preparatory behavior, prior violence, stalking/IPV, intoxication, psychosis/command hallucinations, and protective factors

What is the difference between risk assessment and threat assessment?

Risk assessment focuses on the probability of violence generally; threat assessment focuses on targeted violence toward a specific subject of concern

What does a violence risk assessment aim to determine?

The nature, severity, weapon access, targets, imminence, frequency, context, and likelihood of potential violence

What is the first priority in managing homicidal ideation?

Prioritize immediate safety — assess intent/plan/target/timeframe/weapon access, protect potential victims, restrict lethal means, and use verbal de-escalation

What underlying causes should be evaluated in homicidal ideation?

Intoxication/withdrawal, psychosis or command hallucinations, mania or severe mood disorder, delirium/medical causes, and acute situational/interpersonal crisis

Is there a single medication that treats homicidal ideation?

No — there is no single medication that generically treats 'homicidal ideation'; treat the underlying condition

What legal duties apply when managing a homicidal patient?

Follow applicable duty to protect/warn laws and institutional policy, involve security/law enforcement when necessary, and document the threat, assessment, interventions, and disposition

Is homicidal ideation a diagnosis?

No — homicidal ideation is a symptom, not a diagnosis; management requires simultaneous risk mitigation and treatment of the driving condition