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Therapeutic Management of the Suicidal Patient
According to 1999 data from the Center for Disease Control and Prevention, suicide kills more people than homicide. Suicide was the eleventh leading cause of death (homicide was fourteenth), and the third leading cause of death between ages 15 and 24 years. In the year 1999, 29 199 Americans took their own lives (Hoyert et al., 2001). Suicide and the suicidal patient represent a significant public health problem. The vast majority of people with suicidal intent have a major psychiatric diagnosis. It has been estimated that 90% or more of them can be shown to have a major psychiatric illness (Henriksson et al., 1993; Mann, 2002). Some patients become suicidal, or com-mit suicide with relatively little warning. Others have communicated their intent to a caregiver or significant other. A significant propor-tion, estimated as high as 70%, saw a physician within 30 days prior to their death, and nearly 50% had seen a physician in the preceding week (Barraclough et al., 1974). It was noted in the classic studies of Robins and colleagues (1959) that only 18% of suicidal patients com-municated their intent to helping professionals, while 69% commu-nicated their intent to an average of three close relatives or associates, 73% within 12 months of their suicide (Robins et al., 1959).
Some patients become acutely suicidal while others are chronically at risk. Suicide leaves in its wake intense suffering among the victim’s family and friends, including feelings of grief, anger, shame and frequently guilt. There are relatively limited data on the frequency of suicide attempts. Management of the chronically suicidal is frequently a source of frustration and fear for caregiv-ers. Identifying the risk factors, understanding the suicidal patient and intervening appropriately are key elements in the prevention of suicide. There is a role for parents, families, friends, schools, work-places and physicians in this task. The suicide rates have fallen since 1993 (Hoyert et al., 2001). However, it remains a given that even with due diligence, not all suicides can be predicted or prevented.
Mann and colleagues (1999) have proposed a stress-dia-thesis model of suicidal behavior, as “a psychiatric disorder is generally a necessary but insufficient condition for suicide”. The model posits that suicidal behavior is a function of an individual’s threshold for suicidal acts and the stressors that can lead to vul-nerability. The authors believe that the threshold for suicidal acts is trait-dependent (diathesis), and is mediated by factors such as aggression, impulsivity, substance abuse, family history and low brain serotonin function. Stressors include psychiatric illness and interpersonal problems. In this model, intervention should consider the diathesis as well as the stressors (Mann et al., 1999). Low serotonin levels may be the underlying feature of suicidal behavior, aggression and substance abuse (Mann et al., 1999).
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