Epidemiology
Suicide is the eighth leading cause of death in the United States. Approximately 75 people commit suicide each day in the United States (25,000 per year). Many more people attempt suicide. The overall suicide rate has remained stable in the United States during the past 15 years. Although the rate of suicide in teen-agers aged 15 to 19 is low compared with the general adult population, the rate of teen suicide has risen dramatically in the last 50 years.

Risk Factors
Studies have demonstrated that the overwhelming majority of people who commit suicide have a mental illness (most often a mood disorder or chronic alcoholism). The first-degree relatives of people who have committed suicide are at a much higher risk of committing suicide themselves. Gay and lesbian youth have 2 to 3 times the rate of attef1lpted suicide compared to heterosexual adolescents. Suicide risk increases with age. In men, suicides peak after age 45; in women most suicides occur after age 55. The elderly account for 25% of the suicides, although
they represent only 10% of the population. Overall, men are more successful at completing suicide, perhaps because of their more lethal methods (shooting, hanging, jumping); women often overdose or attempt drowning. Married people have a lower risk of suicide than singles. Suicide is more common among higher social classes, whites, and certain professional groups (physicians, dentists, musicians, law enforcement officers, lawyers, and insurance agents).

Biologic risk factors include low levels of 5- hydroxyindoleacetic acid in the cerebrospinal fluid of patients who have committed suicide by violent means. Among psychological risk factors, hopelessness has been shown to be one of the most reliable indicators of long-term suicide risk.

Clinical Manifestations
History and Mental Status Examination
Most often, a suicide attempt is self-evident at presentation, either because the patient or family indicates that such an event has occurred or because there is an acute medical or surgical emergency (i.e., overdose or wrist laceration). Always obtain further details from the patient and any witnesses to provide a full history of the antecedents and the act itself. Occasionally, a patient will present to a physician in a more subtle way, with nonspecific complaints.
Careful inquiry may reveal that the patient has taken an overdose of a medication with delayed lethality (such as acetaminophen).

Patients who have attempted suicide deserve thorough psychiatric evaluation. Psychiatric history and mental status examination should explicitly address depressive symptoms, such as suicidal thoughts, intent, and plans. The details of the suicide attempt are critical to understanding the risk of a future suicide. Patients who carefully plan the attempt, use particularly violent means, and isolate themselves so as not to be found alive are at particularly high risk of future suicide completion.

Differential Diagnosis
Patients who attempt suicide most commonly suffer from depression, schizophrenia, alcoholism, or personality disorders (or comorbidities of the above).
However, patients who do not meet criteria for any of these disorders can and do attempt or commit suicide, especially if they have any of the risk factors (e.g., hopelessness).

Management
Suicidal ideation should always be taken seriously.

Suicidal patients often are fraught with ambivalence over whether to live or die, and intervention and effective treatment can be lifesaving. Most actively suicidal patients require hospitalization on a locked unit for their own safety. Potentially lethal items should be held securely by nursing staff, and the patient should be observed carefully for the risk of elopement. Treatment of the underlying disorder or distress derives from accurate diagnosis (antidepressants or electroconvulsive therapy [ECT] for depression; antipsychotics and/or mood stabilizers for bipolar disorder, psychotic depression, or schizophrenia).

Patients at Lower risk of suicide can often be managed as outpatients if close follow-up is available, family members are supportive, and a treatment alliance exists. Frequent meetings with treatment providers, eliminating the means of suicide (firearms, potentially toxic prescription pills), and enlisting spouses, partners, or other family members are essential elements of outpatient treatment.