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{{Suicidal ideation}}
{{SI}}
{{CMG}};{{AE}}{{Vbe}}
{{CMG}};{{AE}} [[User:Sharma|Vatsala Sharma, M.B.B.S., M.D.]] {{Vbe}}


{{SK}}  
{{SK}}


==[[Suicidal ideation overview|Overview]]==
==Overview==
Suicidal ideation is characterized by the thoughts of ending one's own life. Suicidal ideation may range in severity from fleeting thoughts to high intent with detailed planning. Patients with [[chronic]] [[medical]] conditions may develop secondary [[depression]] and suicidal ideation that require prompt management. A number of factors such as access to lethal weapons, and poor social support, when coupled with suicidal ideation, may result in a higher probability of completion of the act. In addition, suicidal ideation may coexist with a variety of [[medical]] or psychiatric conditions. Therefore, such patients should be assessed in detail for the presence of suicidal ideation and early intervention should be done to modify the underlying factors.


==[[Suicidal ideation differential diagnosis|Differentiating Suicidal Ideation from other Diseases]]==
==Historical Perspective==
* Meanings of [[suicide]] have varied through the centuries. For the Romans and the Greeks, [[suicide]] was widely accepted. On the contrary, in the periods of early Christianity suicidal behavior was an unacceptable self-murder.<ref name="the direction of Antoon A. Leenaars2002">{{cite journal|last1=the direction of Antoon A. Leenaars|first1=Under|title=Book Reviews|journal=Archives of Suicide Research|volume=6|issue=1|year=2002|pages=75–80|issn=1381-1118|doi=10.1080/13811110213122}}</ref>
* Sir Thomas Browne first coined the term [[suicide]]. It was derived from the Latin words ''Sui'' (of oneself), and ''caedes'' (murder).<ref name="the direction of Antoon A. Leenaars2002">{{cite journal|last1=the direction of Antoon A. Leenaars|first1=Under|title=Book Reviews|journal=Archives of Suicide Research|volume=6|issue=1|year=2002|pages=75–80|issn=1381-1118|doi=10.1080/13811110213122}}</ref>
* [[Suicide]] is a behavior that can be interpreted as communicative action, similar to a language. However, to understand it better one has to be familiar with the society's culture where the act is performed.<ref name="MäkinenBeskow2002">{{cite journal|last1=Mäkinen|first1=Ilkka Henrik|last2=Beskow|first2=Jan|last3=Jansson|first3=Arne|last4=Odén|first4=Birgitta|title=Historical Perspectives on Suicide and Suicide Prevention in Sweden|journal=Archives of Suicide Research|volume=6|issue=3|year=2002|pages=269–284|issn=1381-1118|doi=10.1080/13811110214138}}</ref>
* Over centuries, females have had higher global rates of suicidal ideation and behavior but lower rates of completed [[suicide]] than males.
* The gender-pattern of suicidal ideation has differed across various cultures. In the United States, [[suicide]] is most common among older white men and is typically considered masculine behavior. In other societies, including China, [[suicide]] is viewed as an act of the powerless and is more common in young women.<ref name="Canetto2008">{{cite journal|last1=Canetto|first1=Silvia Sara|title=Women and suicidal behavior: A cultural analysis.|journal=American Journal of Orthopsychiatry|volume=78|issue=2|year=2008|pages=259–266|issn=1939-0025|doi=10.1037/a0013973}}</ref>
*Therefore, there is significant variability in gender patterns and meanings of suicidal ideation and behavior across different cultures.


==[[Suicidal ideation epidemiology and demographics|Epidemiology and Demographics]]==
==Classification==
* Suicidal Ideation can be broadly categorized into passive or active.
* Passive suicidal ideation means imagining or thinking about being dead whereas active ideation includes thinking of plans to die.
* Active ideators are found to be more likely to express self-disgust and self-hatred than passive ideators.<ref name="SzantoReynolds1996">{{cite journal|last1=Szanto|first1=Katalin|last2=Reynolds|first2=Charles F.|last3=Frank|first3=Ellen|last4=Stack|first4=Jacqueline|last5=Fasiczka|first5=Amy L.|last6=Miller|first6=Mark|last7=Mulsant|first7=Benoit H.|last8=Mazumdar|first8=Sati|last9=Kupfer|first9=David J.|title=Suicide in Elderly Depressed Patients: Is Active vs. Passive Suicidal Ideation a Clinically Valid Distinction?|journal=The American Journal of Geriatric Psychiatry|volume=4|issue=3|year=1996|pages=197–207|issn=10647481|doi=10.1097/00019442-199622430-00003}}</ref>
* The active and passive suicidal ideation should not be misinterpreted in elderly patients.It has been found that both groups are equally likely to have had a past history of [[suicide]] attempts.<ref name="SzantoReynolds1996">{{cite journal|last1=Szanto|first1=Katalin|last2=Reynolds|first2=Charles F.|last3=Frank|first3=Ellen|last4=Stack|first4=Jacqueline|last5=Fasiczka|first5=Amy L.|last6=Miller|first6=Mark|last7=Mulsant|first7=Benoit H.|last8=Mazumdar|first8=Sati|last9=Kupfer|first9=David J.|title=Suicide in Elderly Depressed Patients: Is Active vs. Passive Suicidal Ideation a Clinically Valid Distinction?|journal=The American Journal of Geriatric Psychiatry|volume=4|issue=3|year=1996|pages=197–207|issn=10647481|doi=10.1097/00019442-199622430-00003}}</ref>
* The clinicians should not have a lesser degree of vigilance by the presence of passive suicidal ideation. <ref name="SzantoReynolds1996">{{cite journal|last1=Szanto|first1=Katalin|last2=Reynolds|first2=Charles F.|last3=Frank|first3=Ellen|last4=Stack|first4=Jacqueline|last5=Fasiczka|first5=Amy L.|last6=Miller|first6=Mark|last7=Mulsant|first7=Benoit H.|last8=Mazumdar|first8=Sati|last9=Kupfer|first9=David J.|title=Suicide in Elderly Depressed Patients: Is Active vs. Passive Suicidal Ideation a Clinically Valid Distinction?|journal=The American Journal of Geriatric Psychiatry|volume=4|issue=3|year=1996|pages=197–207|issn=10647481|doi=10.1097/00019442-199622430-00003}}</ref>


==[[Suicidal ideation risk factors|Risk Factors]]==
==Pathophysiology==
*The three-step theory that explains the [[pathophysiology]] of suicidal ideation and behavior is: <ref name="KlonskyMay2016">{{cite journal|last1=Klonsky|first1=E. David|last2=May|first2=Alexis M.|last3=Saffer|first3=Boaz Y.|title=Suicide, Suicide Attempts, and Suicidal Ideation|journal=Annual Review of Clinical Psychology|volume=12|issue=1|year=2016|pages=307–330|issn=1548-5943|doi=10.1146/annurev-clinpsy-021815-093204}}</ref>
** The combination of pain and hopelessness produces suicidal ideation.
** Ideation increases if pain exceeds connectedness.
** Acquired contributors to suicidal capacity promote the transition from ideation to attempts.
* Individuals with suicidal ideation and behavior experience chronic activation of the Locus Ceruleus, resulting in synaptic [[norepinephrine]] depletion and compensatory changes in concentrations of noradrenergic proteins.<ref name="pmid9616802">{{cite journal| author=Ordway GA| title=Pathophysiology of the locus coeruleus in suicide. | journal=Ann N Y Acad Sci | year= 1997 | volume= 836 | issue=  | pages= 233-52 | pmid=9616802 | doi=10.1111/j.1749-6632.1997.tb52363.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9616802  }} </ref>
* Cytokine derangement is also observed in patients with suicidal ideation. Elevated interleukin (IL)-6 has been the most consistent finding in CSF, and blood. On postmortem, it was found elevated in the brains of individuals who died by suicide.<ref name="GanançaOquendo2016">{{cite journal|last1=Ganança|first1=Licínia|last2=Oquendo|first2=Maria A.|last3=Tyrka|first3=Audrey R.|last4=Cisneros-Trujillo|first4=Sebastian|last5=Mann|first5=J. John|last6=Sublette|first6=M. Elizabeth|title=The role of cytokines in the pathophysiology of suicidal behavior|journal=Psychoneuroendocrinology|volume=63|year=2016|pages=296–310|issn=03064530|doi=10.1016/j.psyneuen.2015.10.008}}</ref>
*Increased IL-6 level is also associated with more violent attempts and future [[suicide]] completion.<ref name="GanançaOquendo2016">{{cite journal|last1=Ganança|first1=Licínia|last2=Oquendo|first2=Maria A.|last3=Tyrka|first3=Audrey R.|last4=Cisneros-Trujillo|first4=Sebastian|last5=Mann|first5=J. John|last6=Sublette|first6=M. Elizabeth|title=The role of cytokines in the pathophysiology of suicidal behavior|journal=Psychoneuroendocrinology|volume=63|year=2016|pages=296–310|issn=03064530|doi=10.1016/j.psyneuen.2015.10.008}}</ref>
*Endogenous opioids have been found to be involved in the [[pathophysiology]] of suicidal ideation and behavior.<ref name="SherStanley2008">{{cite journal|last1=Sher|first1=Leo|last2=Stanley|first2=Barbara H.|title=The Role of Endogenous Opioids in the Pathophysiology of Self-Injurious and Suicidal Behavior|journal=Archives of Suicide Research|volume=12|issue=4|year=2008|pages=299–308|issn=1381-1118|doi=10.1080/13811110802324748}}</ref>
*Genetic and epigenetic studies show a major role of Brain-derived neurotrophic factors (BDNF) and BDNF receptor tropomyosin-related kinase B (TrkB) in the development of suicidal ideation and behavior. Dysregulation of BDNF gene expression resulting in decreased BDNF activity could alter the vulnerability to stress and increase the risk for [[suicide]]. <ref name="pmid 23995205">{{cite journal| author=Paska AV, Zupanc T, Pregelj P| title=The role of brain-derived neurotrophic factor in the pathophysiology of suicidal behavior. | journal=Psychiatr Danub | year= 2013 | volume= 25 Suppl 2 | issue=  | pages= S341-4 | pmid= 23995205 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23995205  }} </ref>
* It has been noticed that BDNF derangement plays a more significant role in the development of suicidal ideation and behavior in adolescents than in adults. <ref name="pmid22191181">{{cite journal| author=Sher L| title=The role of brain-derived neurotrophic factor in the pathophysiology of adolescent suicidal behavior. | journal=Int J Adolesc Med Health | year= 2011 | volume= 23 | issue= 3 | pages= 181-5 | pmid=22191181 | doi=10.1515/ijamh.2011.041 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22191181  }} </ref>


==[[Suicidal ideation screening|Screening]]==
==Causes==
Common causes of suicidal ideation include <ref name="pmid32643127">{{cite journal| author=Kim YT, Cha C, Lee MR| title=Comparison of causes for suicidal ideation and attempt: Korean Longitudinal Survey of Women and Families. | journal=Arch Womens Ment Health | year= 2020 | volume=  | issue=  | pages=  | pmid=32643127 | doi=10.1007/s00737-020-01048-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32643127  }} </ref><ref name="pmid23518573">{{cite journal| author=van Ours JC, Williams J, Fergusson D, Horwood LJ| title=Cannabis use and suicidal ideation. | journal=J Health Econ | year= 2013 | volume= 32 | issue= 3 | pages= 524-37 | pmid=23518573 | doi=10.1016/j.jhealeco.2013.02.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23518573  }} </ref><ref name="BakkenGunter2012">{{cite journal|last1=Bakken|first1=Nicholas W.|last2=Gunter|first2=Whitney D.|title=Self-Cutting and Suicidal Ideation among Adolescents: Gender Differences in the Causes and Correlates of Self-Injury|journal=Deviant Behavior|volume=33|issue=5|year=2012|pages=339–356|issn=0163-9625|doi=10.1080/01639625.2011.584054}}</ref><ref name="MolinaViola2019">{{cite journal|last1=Molina|first1=Nicolette|last2=Viola|first2=Martin|last3=Rogers|first3=Madeline|last4=Ouyang|first4=Daniel|last5=Gang|first5=James|last6=Derry|first6=Heather|last7=Prigerson|first7=Holly G.|title=Suicidal Ideation in Bereavement: A Systematic Review|journal=Behavioral Sciences|volume=9|issue=5|year=2019|pages=53|issn=2076-328X|doi=10.3390/bs9050053}}</ref><ref name="AbreuLafer2009">{{cite journal|last1=Abreu|first1=Lena Nabuco de|last2=Lafer|first2=Beny|last3=Baca-Garcia|first3=Enrique|last4=Oquendo|first4=Maria A.|title=Suicidal ideation and suicide attempts in bipolar disorder type I: an update for the clinician|journal=Revista Brasileira de Psiquiatria|volume=31|issue=3|year=2009|pages=271–280|issn=1809-452X|doi=10.1590/S1516-44462009005000003}}</ref>


==[[Suicidal ideation natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
* Intensive [[cannabis]] use
* Substance use disorders ([[alcohol]], [[cocaine]], inhalants)
* [[Major depressive disorder]]
* [[Bipolar disorder]]
* [[Bereavement]]
* High stress
* Sexual assault
* [[Medical]] [[comorbidity]]
* Non-marital status
 
==Epidemiology and Demographics==
 
* The prevalence of suicidal ideation is variable in different parts of the world.
 
===Age===
*Patients of all age groups may develop suicidal ideation.
*It is more commonly observed among patients aged more than 75 years.<ref name="pmid11929324">{{cite journal| author=Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF| title=Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. | journal=Drugs Aging | year= 2002 | volume= 19 | issue= 1 | pages= 11-24 | pmid=11929324 | doi=10.2165/00002512-200219010-00002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11929324  }} </ref>
*In younger age groups suicide attempts are often impulsive acts, whereas suicide attempts in individuals aged 65 years and older are often long-planned. <ref name="pmid11929324">{{cite journal| author=Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF| title=Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. | journal=Drugs Aging | year= 2002 | volume= 19 | issue= 1 | pages= 11-24 | pmid=11929324 | doi=10.2165/00002512-200219010-00002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11929324  }} </ref>
*It has been observed that [[depression]] and [[medical illness]] frequently coexist in the elderly and physical illness plays a major role in the development of [[suicidal]] behavior of these patients.<ref name="pmid11929324">{{cite journal| author=Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF| title=Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. | journal=Drugs Aging | year= 2002 | volume= 19 | issue= 1 | pages= 11-24 | pmid=11929324 | doi=10.2165/00002512-200219010-00002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11929324  }} </ref>
 
===Gender===
*Both men and women may develop suicidal ideation.
*Females have been found to have suicidal ideation more commonly than men. However, men have a greater rate of completion of [[suicide]]. This may be explained by the fear of social disapproval, higher [[impulsivity]], and lesser help‐seeking behavior among males.<ref name="AllisonAllison2016">{{cite journal|last1=Allison|first1=Stephen|last2=Allison|first2=Stephen|last3=Roeger|first3=Leigh|last4=Martin|first4=Graham|last5=Keeves|first5=John|title=Gender Differences in the Relationship Between Depression and Suicidal Ideation in Young Adolescents|journal=Australian & New Zealand Journal of Psychiatry|volume=35|issue=4|year=2016|pages=498–503|issn=0004-8674|doi=10.1046/j.1440-1614.2001.00927.x}}</ref><ref name="Beautrais2002">{{cite journal|last1=Beautrais|first1=Annette L|title=Gender issues in youth suicidal behaviour|journal=Emergency Medicine Australasia|volume=14|issue=1|year=2002|pages=35–42|issn=1742-6731|doi=10.1046/j.1442-2026.2002.00283.x}}</ref>
 
===Race===
*There is no racial predilection for suicidal ideation.
*Differences in self-disclosure and mental health service utilization have been noticed among different races. <ref name="MorrisonDowney2000">{{cite journal|last1=Morrison|first1=Linda L.|last2=Downey|first2=Deborah L.|title=Racial differences in self-disclosure of suicidal ideation and reasons for living: Implications for training.|journal=Cultural Diversity and Ethnic Minority Psychology|volume=6|issue=4|year=2000|pages=374–386|issn=1939-0106|doi=10.1037/1099-9809.6.4.374}}</ref><ref name="NestorCheek2016">{{cite journal|last1=Nestor|first1=Bridget A.|last2=Cheek|first2=Shayna M.|last3=Liu|first3=Richard T.|title=Ethnic and racial differences in mental health service utilization for suicidal ideation and behavior in a nationally representative sample of adolescents|journal=Journal of Affective Disorders|volume=202|year=2016|pages=197–202|issn=01650327|doi=10.1016/j.jad.2016.05.021}}</ref>
 
==Risk Factors==
 
The risk factors associated with completed suicide are:<ref name="pmid10193592">{{cite journal| author=Gliatto MF, Rai AK| title=Evaluation and treatment of patients with suicidal ideation. | journal=Am Fam Physician | year= 1999 | volume= 59 | issue= 6 | pages= 1500-6 | pmid=10193592 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10193592  }} </ref><ref name="pmid8444530">{{cite journal| author=Gupta MA, Schork NJ, Gupta AK, Kirkby S, Ellis CN| title=Suicidal ideation in psoriasis. | journal=Int J Dermatol | year= 1993 | volume= 32 | issue= 3 | pages= 188-90 | pmid=8444530 | doi=10.1111/j.1365-4362.1993.tb02790.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8444530  }} </ref><ref name="pmid20550757">{{cite journal| author=Meltzer H, Bebbington P, Brugha T, Jenkins R, McManus S, Dennis MS| title=Personal debt and suicidal ideation. | journal=Psychol Med | year= 2011 | volume= 41 | issue= 4 | pages= 771-8 | pmid=20550757 | doi=10.1017/S0033291710001261 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20550757  }} </ref><ref name="JonesHermann2003">{{cite journal|last1=Jones|first1=Jana E|last2=Hermann|first2=Bruce P|last3=Barry|first3=John J|last4=Gilliam|first4=Frank G|last5=Kanner|first5=Andres M|last6=Meador|first6=Kimford J|title=Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy|journal=Epilepsy & Behavior|volume=4|year=2003|pages=31–38|issn=15255050|doi=10.1016/j.yebeh.2003.08.019}}</ref>
*White males with age greater than 65 years
*Widowed
*Divorced
*Access to [[firearms]]
*Previous [[suicidal]] behavior
*Presence of stressful life events such as multiple debts
*[[Major depressive disorder]]
*Substance abuse
*[[Schizophrenia]]
*[[Borderline Personality Disorder]]
*[[Panic disorder]]
*High [[impulsivity]]
*Medical conditions such as [[cancer]], [[epilepsy]], head injury, [[peptic ulcer disease]], [[psoriasis]] and [[AIDS]].
 
==Screening==
 
*The standardized protocol is used to identify individuals at risk for [[suicide]].
*Various scales have been used to predict [[suicide]] risk in patients with suicidal ideation.
*Screening for [[suicide]] risk in primary care is very important. It can detect suicidal ideation and prompt a referral to a behavioral health care center before a fatal [[suicide]] attempt is made.<ref name="Wintersteen2010">{{cite journal|last1=Wintersteen|first1=M. B.|title=Standardized Screening for Suicidal Adolescents in Primary Care|journal=PEDIATRICS|volume=125|issue=5|year=2010|pages=938–944|issn=0031-4005|doi=10.1542/peds.2009-2458}}</ref>
*Although screening assessment for [[suicide]] risk is only a part of the broader aspect of [[suicide]] risk assessment, a number of clinical rating scales are available:<ref name="Cochrane-BrinkLofchy2000">{{cite journal|last1=Cochrane-Brink|first1=Kate A|last2=Lofchy|first2=Jodi S|last3=Sakinofsky|first3=Isaac|title=Clinical rating scales in suicide risk assessment|journal=General Hospital Psychiatry|volume=22|issue=6|year=2000|pages=445–451|issn=01638343|doi=10.1016/S0163-8343(00)00106-7}}</ref><ref name="DesseillesPerroud2012">{{cite journal|last1=Desseilles|first1=Martin|last2=Perroud|first2=Nader|last3=Guillaume|first3=Sébastien|last4=Jaussent|first4=Isabelle|last5=Genty|first5=Catherine|last6=Malafosse|first6=Alain|last7=Courtet|first7=Philippe|title=Is it valid to measure suicidal ideation by depression rating scales?|journal=Journal of Affective Disorders|volume=136|issue=3|year=2012|pages=398–404|issn=01650327|doi=10.1016/j.jad.2011.11.013}}</ref><ref name="MundtGreist2010">{{cite journal|last1=Mundt|first1=James C.|last2=Greist|first2=John H.|last3=Gelenberg|first3=Alan J.|last4=Katzelnick|first4=David J.|last5=Jefferson|first5=James W.|last6=Modell|first6=Jack G.|title=Feasibility and validation of a computer-automated Columbia-Suicide severity rating scale using interactive voice response technology|journal=Journal of Psychiatric Research|volume=44|issue=16|year=2010|pages=1224–1228|issn=00223956|doi=10.1016/j.jpsychires.2010.04.025}}</ref><ref name="AbeRuneson2017">{{cite journal|last1=Abe|first1=Takeru|last2=Runeson|first2=Bo|last3=Odeberg|first3=Jenny|last4=Pettersson|first4=Agneta|last5=Edbom|first5=Tobias|last6=Jildevik Adamsson|first6=Ingalill|last7=Waern|first7=Margda|title=Instruments for the assessment of suicide risk: A systematic review evaluating the certainty of the evidence|journal=PLOS ONE|volume=12|issue=7|year=2017|pages=e0180292|issn=1932-6203|doi=10.1371/journal.pone.0180292}}</ref><ref name="GutierrezOsman2000">{{cite journal|last1=Gutierrez|first1=Peter M.|last2=Osman|first2=Augustine|last3=Kopper|first3=Beverly A.|last4=Barrios|first4=Francisco X.|last5=Bagge|first5=Courtney L.|title=Suicide risk assessment in a college student population.|journal=Journal of Counseling Psychology|volume=47|issue=4|year=2000|pages=403–413|issn=1939-2168|doi=10.1037/0022-0167.47.4.403}}</ref>
** Columbia Suicide Severity Rating Scale (C-SSRS)
** Beck Scale for Suicidal Ideation (BSS)
** Beck Hopelessness Scale
** Hamilton Scale for Depression (HAM-D)
** SAD PERSONS Scale
** Adult Suicidal Ideation Questionnaire
** Reasons for Living Inventory
** Suicidal Behaviors Questionnaire
 
==Natural History, Complications, and Prognosis==
 
*There is a strong association between current suicidal ideation, history of [[suicide]] attempts, and [[depression]]. It has been observed that past [[suicide]] attempts occur in the context of psychosocial dysfunction.<ref name="RobertsRoberts1998">{{cite journal|last1=Roberts|first1=Robert K.|last2=Roberts|first2=Catherine R.|last3=Chen|first3=Y. Richard|title=Suicidal Thinking Among Adolescents With a History of Attempted Suicide|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=37|issue=12|year=1998|pages=1294–1300|issn=08908567|doi=10.1097/00004583-199812000-00013}}</ref>
*Elderly patients with severe [[depression]], a history of [[suicide]] attempts with high intent, and poor social support are likely to have suicidal ideation and should be targeted for management. The severity of [[depression]] is the strongest predictor of the course of suicidal ideation.<ref name="AlexopoulosBruce1999">{{cite journal|last1=Alexopoulos|first1=George S.|last2=Bruce|first2=Martha L.|last3=Hull|first3=James|last4=Sirey|first4=Jo Anne|last5=Kakuma|first5=Tatsuyuki|title=Clinical Determinants of Suicidal Ideation and Behavior in Geriatric Depression|journal=Archives of General Psychiatry|volume=56|issue=11|year=1999|pages=1048|issn=0003-990X|doi=10.1001/archpsyc.56.11.1048}}</ref>
*Hopelessness is an important clinical marker of suicidal ideation in terminally ill patients. Hopelessness has been more highly correlated with suicidal ideation than the severity of [[depression]] in these patients.<ref name="ChochinovWilson1998">{{cite journal|last1=Chochinov|first1=Harvey Max|last2=Wilson|first2=Keith G.|last3=Enns|first3=Murray|last4=Lander|first4=Sheila|title=Depression, Hopelessness, and Suicidal Ideation in the Terminally Ill|journal=Psychosomatics|volume=39|issue=4|year=1998|pages=366–370|issn=00333182|doi=10.1016/S0033-3182(98)71325-8}}</ref>
*It has been noticed that [[eating disorders]] are associated with high levels of [[comorbidity]] and [[suicidality]]. In these individuals, current suicidal ideation has also been linked with higher levels of Axes I and II [[comorbidity]].<ref name="MilosSpindler2004">{{cite journal|last1=Milos|first1=Gabriella|last2=Spindler|first2=Anja|last3=Hepp|first3=Urs|last4=Schnyder|first4=Ulrich|title=Suicide attempts and suicidal ideation: links with psychiatric comorbidity in eating disorder subjects|journal=General Hospital Psychiatry|volume=26|issue=2|year=2004|pages=129–135|issn=01638343|doi=10.1016/j.genhosppsych.2003.10.005}}</ref>


==Diagnosis==
==Diagnosis==
[[Suicidal ideation diagnostic study of choice|Diagnostic study of choice]] | [[Suicidal ideation history and symptoms|History and Symptoms]] | [[Suicidal ideation physical examination|Physical Examination]] | [[Suicidal ideation electrocardiogram|Electrocardiogram]] | [[Suicidal ideation laboratory findings|Laboratory Findings]] | [[Suicidal ideation chest x ray|X-Ray Findings]] | [[Suicidal ideation echocardiography or ultrasound|Echocardiography and Ultrasound]] | [[Suicidal ideation CT|CT-Scan Findings]] | [[Suicidal ideation MRI|MRI Findings]] | [[Suicidal ideation other diagnostic studies|Other Diagnostic Studies]] | [[Suicidal ideation other imaging findings|Other Imaging Findings]]
 
===History and Symptoms===
 
Patients with suicidal ideation are more likely to complete [[suicide]] if they have the following symptoms:<ref name="pmid10193592">{{cite journal| author=Gliatto MF, Rai AK| title=Evaluation and treatment of patients with suicidal ideation. | journal=Am Fam Physician | year= 1999 | volume= 59 | issue= 6 | pages= 1500-6 | pmid=10193592 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10193592  }} </ref>
*[[Anhedonia]]
*[[Insomnia]]
*Hopelessness
*Impaired concentration
*Psychomotor agitation
*Severe [[anxiety]]
 
The [[mental status examination|mental status examination]] is essential for any patient with suicidal ideation. However, a complete physical examination should be done first to rule out organic conditions that might be causing suicidal ideation.
 
===Mental status examination===
 
*A detailed [[mental status examination]] is necessary for a patient with suicidal ideation. There may be slight variation in the [[mental status examination]] based on the underlying [[psychiatric]] condition.
*The mental status examination includes evaluation of appearance, [[behavior]], ability to cooperate with the examiner, level of activity, [[speech]], [[Mood (psychology)|mood]], [[Affect (psychology)|affect]], [[thought]] process and content, [[perception]], [[cognition]], insight, and judgment.
*While performing the [[mental status examination]] of patients with psychiatric conditions, it is always recommended to ask about any suicidal or [[homicidal ideation]].
*Assessment should take special consideration about the length of most recent suicidal ideation, and frequency as well as the intensity of suicidal ideation.<ref name="MirandaOrtin2014">{{cite journal|last1=Miranda|first1=Regina|last2=Ortin|first2=Ana|last3=Scott|first3=Michelle|last4=Shaffer|first4=David|title=Characteristics of suicidal ideation that predict the transition to future suicide attempts in adolescents|journal=Journal of Child Psychology and Psychiatry|volume=55|issue=11|year=2014|pages=1288–1296|issn=00219630|doi=10.1111/jcpp.12245}}</ref><ref name="BorgesNazem2019">{{cite journal|last1=Borges|first1=Lauren M.|last2=Nazem|first2=Sarra|last3=Matarazzo|first3=Bridget B.|last4=Barnes|first4=Sean M.|last5=Wortzel|first5=Hal S.|title=Therapeutic Risk Management|journal=Journal of Psychiatric Practice|volume=25|issue=1|year=2019|pages=46–53|issn=1538-1145|doi=10.1097/PRA.0000000000000358}}</ref>


==Treatment==
==Treatment==
[[Suicidal ideation medical therapy|Medical Therapy]] | [[Suicidal ideation surgery|Surgery]] | [[Suicidal ideation primary prevention|Primary Prevention]] | [[Suicidal ideation secondary prevention|Secondary Prevention]] | [[Suicidal ideation cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Suicidal ideation future or investigational therapies|Future or Investigational Therapies]]
*Treatment depends on whether it is an emergency situation that requires active intervention or just passive suicidal ideation that can be addressed by outpatient management.
*As compared to the younger patients, the management of suicidal ideation is multifaceted for the elderly. Effective interventions for this population are primary care-based [[depression]] [[screening]] and management programs; treatment [[interventions]] ([[pharmacotherapy]] and [[psychotherapy]]); telephone counseling; and community-based programs incorporating education, gatekeeper training, [[depression]] screening, and various group activities. <ref name="OkolieDennis2017">{{cite journal|last1=Okolie|first1=Chukwudi|last2=Dennis|first2=Michael|last3=Simon Thomas|first3=Emily|last4=John|first4=Ann|title=A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people|journal=International Psychogeriatrics|volume=29|issue=11|year=2017|pages=1801–1824|issn=1041-6102|doi=10.1017/S1041610217001430}}</ref>
*[[Primary care]]-based collaborative programs for depression is a strategy to reduce suicidal ideation in older [[primary care]] patients.<ref name="UnützerTang2006">{{cite journal|last1=Unützer|first1=Jürgen|last2=Tang|first2=Lingqi|last3=Oishi|first3=Sabine|last4=Katon|first4=Wayne|last5=Williams|first5=John W.|last6=Hunkeler|first6=Enid|last7=Hendrie|first7=Hugh|last8=Lin|first8=Elizabeth H.B.|last9=Levine|first9=Stuart|last10=Grypma|first10=Lydia|last11=Steffens|first11=David C.|last12=Fields|first12=Julie|last13=Langston|first13=Christopher|title=Reducing Suicidal Ideation in Depressed Older Primary Care Patients|journal=Journal of the American Geriatrics Society|volume=54|issue=10|year=2006|pages=1550–1556|issn=00028614|doi=10.1111/j.1532-5415.2006.00882.x}}</ref>
*Sustained collaborative care maintains high utilization of [[depression]] treatment, improves the outcomes of major [[depression]] and, reduces suicidal ideation.<ref name="AlexopoulosReynolds2009">{{cite journal|last1=Alexopoulos|first1=George S.|last2=Reynolds|first2=Charles F.|last3=Bruce|first3=Martha L.|last4=Katz|first4=Ira R.|last5=Raue|first5=Patrick J.|last6=Mulsant|first6=Benoit H.|last7=Oslin|first7=David W.|last8=Ten Have|first8=Thomas|title=Reducing Suicidal Ideation and Depression in Older Primary Care Patients: 24-Month Outcomes of the PROSPECT Study|journal=American Journal of Psychiatry|volume=166|issue=8|year=2009|pages=882–890|issn=0002-953X|doi=10.1176/appi.ajp.2009.08121779}}</ref>
*The management of suicidal ideation mainly consists of [[pharmacotherapy]] and [[psychotherapy]].
 
===Pharmacotherapy===
*Although Selective Serotonin Reuptake Inhibitors (SSRI) have been commonly used to treat depression, in 2004 the FDA labeled a black box warning stating there was an increased risk of [[suicide]] when these medications were used in children and adolescents.<ref name="GibbonsBrown2007">{{cite journal|last1=Gibbons|first1=Robert D.|last2=Brown|first2=C. Hendricks|last3=Hur|first3=Kwan|last4=Marcus|first4=Sue M.|last5=Bhaumik|first5=Dulal K.|last6=Erkens|first6=Joëlle A.|last7=Herings|first7=Ron M.C.|last8=Mann|first8=J. John|title=Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents|journal=American Journal of Psychiatry|volume=164|issue=9|year=2007|pages=1356–1363|issn=0002-953X|doi=10.1176/appi.ajp.2007.07030454}}</ref>
*There had been a decrease in the use of [[antidepressant]] therapy in children and adolescents following this black box warning.<ref name="pmid20011576">{{cite journal| author=Singh T, Prakash A, Rais T, Kumari N| title=Decreased Use of Antidepressants in Youth After US Food and Drug Administration Black Box Warning. | journal=Psychiatry (Edgmont) | year= 2009 | volume= 6 | issue= 10 | pages= 30-4 | pmid=20011576 | doi= | pmc=2790401 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20011576  }} </ref>
*In [[bipolar disorder]], and also unipolar major [[depression]], long-term treatment with lithium has preventive effects on [[suicidal]] behavior.<ref name="TondoBaldessarini2016">{{cite journal|last1=Tondo|first1=Leonardo|last2=Baldessarini|first2=Ross J.|title=Suicidal Behavior in Mood Disorders: Response to Pharmacological Treatment|journal=Current Psychiatry Reports|volume=18|issue=9|year=2016|issn=1523-3812|doi=10.1007/s11920-016-0715-0}}</ref>
*Suicidal ideation associated with treatment-resistant [[major depressive disorder]] rapidly improves after infusion of an N-Methy-D-Asparatate (NMDA) receptor antagonist, ketamine.<ref name="DiazGranadosIbrahim2010">{{cite journal|last1=DiazGranados|first1=Nancy|last2=Ibrahim|first2=Lobna A.|last3=Brutsche|first3=Nancy E.|last4=Ameli|first4=Rezvan|last5=Henter|first5=Ioline D.|last6=Luckenbaugh|first6=David A.|last7=Machado-Vieira|first7=Rodrigo|last8=Zarate|first8=Carlos A.|title=Rapid Resolution of Suicidal Ideation After a Single Infusion of anN-Methyl-D-Aspartate Antagonist in Patients With Treatment-Resistant Major Depressive Disorder|journal=The Journal of Clinical Psychiatry|volume=71|issue=12|year=2010|pages=1605–1611|issn=0160-6689|doi=10.4088/JCP.09m05327blu}}</ref>
*The short-term use of low dose sublingual buprenorphine is found to be associated with decreased suicidal ideation in severely [[suicidal]] patients without substance abuse.<ref name="YovellBar2016">{{cite journal|last1=Yovell|first1=Yoram|last2=Bar|first2=Gali|last3=Mashiah|first3=Moti|last4=Baruch|first4=Yehuda|last5=Briskman|first5=Irina|last6=Asherov|first6=Jack|last7=Lotan|first7=Amit|last8=Rigbi|first8=Amihai|last9=Panksepp|first9=Jaak|title=Ultra-Low-Dose Buprenorphine as a Time-Limited Treatment for Severe Suicidal Ideation: A Randomized Controlled Trial|journal=American Journal of Psychiatry|volume=173|issue=5|year=2016|pages=491–498|issn=0002-953X|doi=10.1176/appi.ajp.2015.15040535}}</ref>
 
===Psychotherapy===
*In patients with [[schizophrenia]], [[cognitive behavioral therapy]] (CBT) provides significant reduction in suicidal ideation at the end of therapy, and is sustained at the follow-up.<ref name="BatemanHansen2007">{{cite journal|last1=Bateman|first1=Katy|last2=Hansen|first2=Lars|last3=Turkington|first3=Douglas|last4=Kingdon|first4=David|title=Cognitive Behavioral Therapy Reduces Suicidal Ideation in Schizophrenia: Results from a Randomized Controlled Trial|journal=Suicide and Life-Threatening Behavior|volume=37|issue=3|year=2007|pages=284–290|issn=03630234|doi=10.1521/suli.2007.37.3.284}}</ref>
*Acceptance and Commitment Therapy (ACT) can be used as an adjunctive strategy in programs for [[suicide]] prevention. It is effective in reducing suicidal ideation and improving the clinical dimensions associated with [[suicidal]] risk. <ref name="DucasseJaussent2018">{{cite journal|last1=Ducasse|first1=Déborah|last2=Jaussent|first2=Isabelle|last3=Arpon-Brand|first3=Véronique|last4=Vienot|first4=Marina|last5=Laglaoui|first5=Camelia|last6=Béziat|first6=Séverine|last7=Calati|first7=Raffaella|last8=Carrière|first8=Isabelle|last9=Guillaume|first9=Sébastien|last10=Courtet|first10=Philippe|last11=Olié|first11=Emilie|title=Acceptance and Commitment Therapy for the Management of Suicidal Patients: A Randomized Controlled Trial|journal=Psychotherapy and Psychosomatics|volume=87|issue=4|year=2018|pages=211–222|issn=0033-3190|doi=10.1159/000488715}}</ref>
*Attachment-Based Family Therapy has been more effective than Enhanced Usual Care (EUC) in reducing suicidal ideation and [[depressive]] symptoms in [[adolescents]].<ref name="DiamondWintersteen2010">{{cite journal|last1=Diamond|first1=Guy S.|last2=Wintersteen|first2=Matthew B.|last3=Brown|first3=Gregory K.|last4=Diamond|first4=Gary M.|last5=Gallop|first5=Robert|last6=Shelef|first6=Karni|last7=Levy|first7=Suzanne|title=Attachment-Based Family Therapy for Adolescents with Suicidal Ideation: A Randomized Controlled Trial|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=49|issue=2|year=2010|pages=122–131|issn=08908567|doi=10.1016/j.jaac.2009.11.002}}</ref>
*Intensive school‐based interpersonal [[psychotherapy]] for depressed adolescents with [[suicidal]] risk (IPT‐A‐IN) is effective in reducing the severity of [[depression]], and suicidal ideation in these individuals.<ref name="TangJou2009">{{cite journal|last1=Tang|first1=Tze-Chun|last2=Jou|first2=Shaw-Hwa|last3=Ko|first3=Chih-Hung|last4=Huang|first4=Shih-Yin|last5=Yen|first5=Cheng-Fang|title=Randomized study of school-based intensive interpersonal psychotherapy for depressed adolescents with suicidal risk and parasuicide behaviors|journal=Psychiatry and Clinical Neurosciences|volume=63|issue=4|year=2009|pages=463–470|issn=13231316|doi=10.1111/j.1440-1819.2009.01991.x}}</ref>
*Problem Solving Therapy (PST) is found to be more effective than Supportive Therapy (ST) in reducing suicidal ideation in elderly patients with [[major depression]] and executive dysfunction.<ref name="GustavsonAlexopoulos2016">{{cite journal|last1=Gustavson|first1=Kristen A.|last2=Alexopoulos|first2=George S.|last3=Niu|first3=Grace C.|last4=McCulloch|first4=Charles|last5=Meade|first5=Tanya|last6=Areán|first6=Patricia A.|title=Problem-Solving Therapy Reduces Suicidal Ideation In Depressed Older Adults with Executive Dysfunction|journal=The American Journal of Geriatric Psychiatry|volume=24|issue=1|year=2016|pages=11–17|issn=10647481|doi=10.1016/j.jagp.2015.07.010}}</ref>
 
===Prevention===
*Universal [[suicide]] risk [[screening]] programs can be used to identify youth in medical settings who may otherwise pass through the system with undetected [[suicide]] risk.<ref name="pmid32358211">{{cite journal| author=Horowitz L, Tipton MV, Pao M| title=Primary and Secondary Prevention of Youth Suicide. | journal=Pediatrics | year= 2020 | volume= 145 | issue= Suppl 2 | pages= S195-S203 | pmid=32358211 | doi=10.1542/peds.2019-2056H | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32358211  }} </ref>
*Educating the [[primary care]] agencies to be vigilant for signs and symptoms of [[depression]] may reduce the probability of [[suicide]]. Secondary prevention of suicidal behavior warrants structured [[psychotherapy]] focused on problem-solving and emotion regulation.<ref name="WilliamsPollock2009">{{cite journal|last1=Williams|first1=J Mark G|last2=Pollock|first2=Leslie R|title=Factors mediating suicidal behaviour: Their utility in primary and secondary prevention|journal=Journal of Mental Health|volume=2|issue=1|year=2009|pages=3–26|issn=0963-8237|doi=10.3109/09638239309016951}}</ref>
*For secondary prevention, there are five major methods: [[pharmacological]] management, [[psychological]] interventions, follow-up care, reduced access to lethal means, and responsible media reporting of [[suicides]].<ref name="GanzBraquehais2010">{{cite journal|last1=Ganz|first1=Debora|last2=Braquehais|first2=M. Dolores|last3=Sher|first3=Leo|title=Secondary Prevention of Suicide|journal=PLoS Medicine|volume=7|issue=6|year=2010|pages=e1000271|issn=1549-1676|doi=10.1371/journal.pmed.1000271}}</ref>
*The [[Suicide]] Behavior Prevention Program (SBPP) is a secondary preventive intervention found to be effective in delaying and preventing [[suicide]] reattempts within the first year after the [[suicide]].<ref name="FarréPortella2016">{{cite journal|last1=Farré|first1=Adriana|last2=Portella|first2=Maria J.|last3=De Angel|first3=Luis|last4=Díaz|first4=Ana|last5=de Diego-Adeliño|first5=Javier|last6=Vegué|first6=Joan|last7=Duran-Sindreu|first7=Santiago|last8=Faus|first8=Gustavo|last9=Tejedor|first9=Carmen|last10=Álvarez|first10=Enric|last11=Pérez|first11=Víctor|title=Benefits of a Secondary Prevention Program in Suicide|journal=Crisis|volume=37|issue=4|year=2016|pages=281–289|issn=0227-5910|doi=10.1027/0227-5910/a000388}}</ref>
 
Further research is needed to identify factors that increase suicide risk over years, months, weeks, days, hours, or minutes. A better understanding is also required in terms of different risk profiles and predictors for fatal and nonfatal [[suicide]] attempts.<ref name="KlonskyMay2016">{{cite journal|last1=Klonsky|first1=E. David|last2=May|first2=Alexis M.|last3=Saffer|first3=Boaz Y.|title=Suicide, Suicide Attempts, and Suicidal Ideation|journal=Annual Review of Clinical Psychology|volume=12|issue=1|year=2016|pages=307–330|issn=1548-5943|doi=10.1146/annurev-clinpsy-021815-093204}}</ref>
 
==References==
{{reflist|2}}
 
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vatsala Sharma, M.B.B.S., M.D. Vindhya BellamKonda, M.B.B.S [2]

Synonyms and keywords:

Overview

Suicidal ideation is characterized by the thoughts of ending one's own life. Suicidal ideation may range in severity from fleeting thoughts to high intent with detailed planning. Patients with chronic medical conditions may develop secondary depression and suicidal ideation that require prompt management. A number of factors such as access to lethal weapons, and poor social support, when coupled with suicidal ideation, may result in a higher probability of completion of the act. In addition, suicidal ideation may coexist with a variety of medical or psychiatric conditions. Therefore, such patients should be assessed in detail for the presence of suicidal ideation and early intervention should be done to modify the underlying factors.

Historical Perspective

  • Meanings of suicide have varied through the centuries. For the Romans and the Greeks, suicide was widely accepted. On the contrary, in the periods of early Christianity suicidal behavior was an unacceptable self-murder.[1]
  • Sir Thomas Browne first coined the term suicide. It was derived from the Latin words Sui (of oneself), and caedes (murder).[1]
  • Suicide is a behavior that can be interpreted as communicative action, similar to a language. However, to understand it better one has to be familiar with the society's culture where the act is performed.[2]
  • Over centuries, females have had higher global rates of suicidal ideation and behavior but lower rates of completed suicide than males.
  • The gender-pattern of suicidal ideation has differed across various cultures. In the United States, suicide is most common among older white men and is typically considered masculine behavior. In other societies, including China, suicide is viewed as an act of the powerless and is more common in young women.[3]
  • Therefore, there is significant variability in gender patterns and meanings of suicidal ideation and behavior across different cultures.

Classification

  • Suicidal Ideation can be broadly categorized into passive or active.
  • Passive suicidal ideation means imagining or thinking about being dead whereas active ideation includes thinking of plans to die.
  • Active ideators are found to be more likely to express self-disgust and self-hatred than passive ideators.[4]
  • The active and passive suicidal ideation should not be misinterpreted in elderly patients.It has been found that both groups are equally likely to have had a past history of suicide attempts.[4]
  • The clinicians should not have a lesser degree of vigilance by the presence of passive suicidal ideation. [4]

Pathophysiology

  • The three-step theory that explains the pathophysiology of suicidal ideation and behavior is: [5]
    • The combination of pain and hopelessness produces suicidal ideation.
    • Ideation increases if pain exceeds connectedness.
    • Acquired contributors to suicidal capacity promote the transition from ideation to attempts.
  • Individuals with suicidal ideation and behavior experience chronic activation of the Locus Ceruleus, resulting in synaptic norepinephrine depletion and compensatory changes in concentrations of noradrenergic proteins.[6]
  • Cytokine derangement is also observed in patients with suicidal ideation. Elevated interleukin (IL)-6 has been the most consistent finding in CSF, and blood. On postmortem, it was found elevated in the brains of individuals who died by suicide.[7]
  • Increased IL-6 level is also associated with more violent attempts and future suicide completion.[7]
  • Endogenous opioids have been found to be involved in the pathophysiology of suicidal ideation and behavior.[8]
  • Genetic and epigenetic studies show a major role of Brain-derived neurotrophic factors (BDNF) and BDNF receptor tropomyosin-related kinase B (TrkB) in the development of suicidal ideation and behavior. Dysregulation of BDNF gene expression resulting in decreased BDNF activity could alter the vulnerability to stress and increase the risk for suicide. [9]
  • It has been noticed that BDNF derangement plays a more significant role in the development of suicidal ideation and behavior in adolescents than in adults. [10]

Causes

Common causes of suicidal ideation include [11][12][13][14][15]

Epidemiology and Demographics

  • The prevalence of suicidal ideation is variable in different parts of the world.

Age

  • Patients of all age groups may develop suicidal ideation.
  • It is more commonly observed among patients aged more than 75 years.[16]
  • In younger age groups suicide attempts are often impulsive acts, whereas suicide attempts in individuals aged 65 years and older are often long-planned. [16]
  • It has been observed that depression and medical illness frequently coexist in the elderly and physical illness plays a major role in the development of suicidal behavior of these patients.[16]

Gender

  • Both men and women may develop suicidal ideation.
  • Females have been found to have suicidal ideation more commonly than men. However, men have a greater rate of completion of suicide. This may be explained by the fear of social disapproval, higher impulsivity, and lesser help‐seeking behavior among males.[17][18]

Race

  • There is no racial predilection for suicidal ideation.
  • Differences in self-disclosure and mental health service utilization have been noticed among different races. [19][20]

Risk Factors

The risk factors associated with completed suicide are:[21][22][23][24]

Screening

  • The standardized protocol is used to identify individuals at risk for suicide.
  • Various scales have been used to predict suicide risk in patients with suicidal ideation.
  • Screening for suicide risk in primary care is very important. It can detect suicidal ideation and prompt a referral to a behavioral health care center before a fatal suicide attempt is made.[25]
  • Although screening assessment for suicide risk is only a part of the broader aspect of suicide risk assessment, a number of clinical rating scales are available:[26][27][28][29][30]
    • Columbia Suicide Severity Rating Scale (C-SSRS)
    • Beck Scale for Suicidal Ideation (BSS)
    • Beck Hopelessness Scale
    • Hamilton Scale for Depression (HAM-D)
    • SAD PERSONS Scale
    • Adult Suicidal Ideation Questionnaire
    • Reasons for Living Inventory
    • Suicidal Behaviors Questionnaire

Natural History, Complications, and Prognosis

  • There is a strong association between current suicidal ideation, history of suicide attempts, and depression. It has been observed that past suicide attempts occur in the context of psychosocial dysfunction.[31]
  • Elderly patients with severe depression, a history of suicide attempts with high intent, and poor social support are likely to have suicidal ideation and should be targeted for management. The severity of depression is the strongest predictor of the course of suicidal ideation.[32]
  • Hopelessness is an important clinical marker of suicidal ideation in terminally ill patients. Hopelessness has been more highly correlated with suicidal ideation than the severity of depression in these patients.[33]
  • It has been noticed that eating disorders are associated with high levels of comorbidity and suicidality. In these individuals, current suicidal ideation has also been linked with higher levels of Axes I and II comorbidity.[34]

Diagnosis

History and Symptoms

Patients with suicidal ideation are more likely to complete suicide if they have the following symptoms:[21]

The mental status examination is essential for any patient with suicidal ideation. However, a complete physical examination should be done first to rule out organic conditions that might be causing suicidal ideation.

Mental status examination

Treatment

  • Treatment depends on whether it is an emergency situation that requires active intervention or just passive suicidal ideation that can be addressed by outpatient management.
  • As compared to the younger patients, the management of suicidal ideation is multifaceted for the elderly. Effective interventions for this population are primary care-based depression screening and management programs; treatment interventions (pharmacotherapy and psychotherapy); telephone counseling; and community-based programs incorporating education, gatekeeper training, depression screening, and various group activities. [37]
  • Primary care-based collaborative programs for depression is a strategy to reduce suicidal ideation in older primary care patients.[38]
  • Sustained collaborative care maintains high utilization of depression treatment, improves the outcomes of major depression and, reduces suicidal ideation.[39]
  • The management of suicidal ideation mainly consists of pharmacotherapy and psychotherapy.

Pharmacotherapy

  • Although Selective Serotonin Reuptake Inhibitors (SSRI) have been commonly used to treat depression, in 2004 the FDA labeled a black box warning stating there was an increased risk of suicide when these medications were used in children and adolescents.[40]
  • There had been a decrease in the use of antidepressant therapy in children and adolescents following this black box warning.[41]
  • In bipolar disorder, and also unipolar major depression, long-term treatment with lithium has preventive effects on suicidal behavior.[42]
  • Suicidal ideation associated with treatment-resistant major depressive disorder rapidly improves after infusion of an N-Methy-D-Asparatate (NMDA) receptor antagonist, ketamine.[43]
  • The short-term use of low dose sublingual buprenorphine is found to be associated with decreased suicidal ideation in severely suicidal patients without substance abuse.[44]

Psychotherapy

  • In patients with schizophrenia, cognitive behavioral therapy (CBT) provides significant reduction in suicidal ideation at the end of therapy, and is sustained at the follow-up.[45]
  • Acceptance and Commitment Therapy (ACT) can be used as an adjunctive strategy in programs for suicide prevention. It is effective in reducing suicidal ideation and improving the clinical dimensions associated with suicidal risk. [46]
  • Attachment-Based Family Therapy has been more effective than Enhanced Usual Care (EUC) in reducing suicidal ideation and depressive symptoms in adolescents.[47]
  • Intensive school‐based interpersonal psychotherapy for depressed adolescents with suicidal risk (IPT‐A‐IN) is effective in reducing the severity of depression, and suicidal ideation in these individuals.[48]
  • Problem Solving Therapy (PST) is found to be more effective than Supportive Therapy (ST) in reducing suicidal ideation in elderly patients with major depression and executive dysfunction.[49]

Prevention

  • Universal suicide risk screening programs can be used to identify youth in medical settings who may otherwise pass through the system with undetected suicide risk.[50]
  • Educating the primary care agencies to be vigilant for signs and symptoms of depression may reduce the probability of suicide. Secondary prevention of suicidal behavior warrants structured psychotherapy focused on problem-solving and emotion regulation.[51]
  • For secondary prevention, there are five major methods: pharmacological management, psychological interventions, follow-up care, reduced access to lethal means, and responsible media reporting of suicides.[52]
  • The Suicide Behavior Prevention Program (SBPP) is a secondary preventive intervention found to be effective in delaying and preventing suicide reattempts within the first year after the suicide.[53]

Further research is needed to identify factors that increase suicide risk over years, months, weeks, days, hours, or minutes. A better understanding is also required in terms of different risk profiles and predictors for fatal and nonfatal suicide attempts.[5]

References

  1. ↑ 1.0 1.1 the direction of Antoon A. Leenaars, Under (2002). "Book Reviews". Archives of Suicide Research. 6 (1): 75–80. doi:10.1080/13811110213122. ISSN 1381-1118.
  2. ↑ Mäkinen, Ilkka Henrik; Beskow, Jan; Jansson, Arne; Odén, Birgitta (2002). "Historical Perspectives on Suicide and Suicide Prevention in Sweden". Archives of Suicide Research. 6 (3): 269–284. doi:10.1080/13811110214138. ISSN 1381-1118.
  3. ↑ Canetto, Silvia Sara (2008). "Women and suicidal behavior: A cultural analysis". American Journal of Orthopsychiatry. 78 (2): 259–266. doi:10.1037/a0013973. ISSN 1939-0025.
  4. ↑ 4.0 4.1 4.2 Szanto, Katalin; Reynolds, Charles F.; Frank, Ellen; Stack, Jacqueline; Fasiczka, Amy L.; Miller, Mark; Mulsant, Benoit H.; Mazumdar, Sati; Kupfer, David J. (1996). "Suicide in Elderly Depressed Patients: Is Active vs. Passive Suicidal Ideation a Clinically Valid Distinction?". The American Journal of Geriatric Psychiatry. 4 (3): 197–207. doi:10.1097/00019442-199622430-00003. ISSN 1064-7481.
  5. ↑ 5.0 5.1 Klonsky, E. David; May, Alexis M.; Saffer, Boaz Y. (2016). "Suicide, Suicide Attempts, and Suicidal Ideation". Annual Review of Clinical Psychology. 12 (1): 307–330. doi:10.1146/annurev-clinpsy-021815-093204. ISSN 1548-5943.
  6. ↑ Ordway GA (1997). "Pathophysiology of the locus coeruleus in suicide". Ann N Y Acad Sci. 836: 233–52. doi:10.1111/j.1749-6632.1997.tb52363.x. PMID 9616802.
  7. ↑ 7.0 7.1 Ganança, Licínia; Oquendo, Maria A.; Tyrka, Audrey R.; Cisneros-Trujillo, Sebastian; Mann, J. John; Sublette, M. Elizabeth (2016). "The role of cytokines in the pathophysiology of suicidal behavior". Psychoneuroendocrinology. 63: 296–310. doi:10.1016/j.psyneuen.2015.10.008. ISSN 0306-4530.
  8. ↑ Sher, Leo; Stanley, Barbara H. (2008). "The Role of Endogenous Opioids in the Pathophysiology of Self-Injurious and Suicidal Behavior". Archives of Suicide Research. 12 (4): 299–308. doi:10.1080/13811110802324748. ISSN 1381-1118.
  9. ↑ Paska AV, Zupanc T, Pregelj P (2013). "The role of brain-derived neurotrophic factor in the pathophysiology of suicidal behavior". Psychiatr Danub. 25 Suppl 2: S341–4. PMID 23995205.
  10. ↑ Sher L (2011). "The role of brain-derived neurotrophic factor in the pathophysiology of adolescent suicidal behavior". Int J Adolesc Med Health. 23 (3): 181–5. doi:10.1515/ijamh.2011.041. PMID 22191181.
  11. ↑ Kim YT, Cha C, Lee MR (2020). "Comparison of causes for suicidal ideation and attempt: Korean Longitudinal Survey of Women and Families". Arch Womens Ment Health. doi:10.1007/s00737-020-01048-6. PMID 32643127 Check |pmid= value (help).
  12. ↑ van Ours JC, Williams J, Fergusson D, Horwood LJ (2013). "Cannabis use and suicidal ideation". J Health Econ. 32 (3): 524–37. doi:10.1016/j.jhealeco.2013.02.002. PMID 23518573.
  13. ↑ Bakken, Nicholas W.; Gunter, Whitney D. (2012). "Self-Cutting and Suicidal Ideation among Adolescents: Gender Differences in the Causes and Correlates of Self-Injury". Deviant Behavior. 33 (5): 339–356. doi:10.1080/01639625.2011.584054. ISSN 0163-9625.
  14. ↑ Molina, Nicolette; Viola, Martin; Rogers, Madeline; Ouyang, Daniel; Gang, James; Derry, Heather; Prigerson, Holly G. (2019). "Suicidal Ideation in Bereavement: A Systematic Review". Behavioral Sciences. 9 (5): 53. doi:10.3390/bs9050053. ISSN 2076-328X.
  15. ↑ Abreu, Lena Nabuco de; Lafer, Beny; Baca-Garcia, Enrique; Oquendo, Maria A. (2009). "Suicidal ideation and suicide attempts in bipolar disorder type I: an update for the clinician". Revista Brasileira de Psiquiatria. 31 (3): 271–280. doi:10.1590/S1516-44462009005000003. ISSN 1809-452X.
  16. ↑ 16.0 16.1 16.2 Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF (2002). "Identification of suicidal ideation and prevention of suicidal behaviour in the elderly". Drugs Aging. 19 (1): 11–24. doi:10.2165/00002512-200219010-00002. PMID 11929324.
  17. ↑ Allison, Stephen; Allison, Stephen; Roeger, Leigh; Martin, Graham; Keeves, John (2016). "Gender Differences in the Relationship Between Depression and Suicidal Ideation in Young Adolescents". Australian & New Zealand Journal of Psychiatry. 35 (4): 498–503. doi:10.1046/j.1440-1614.2001.00927.x. ISSN 0004-8674.
  18. ↑ Beautrais, Annette L (2002). "Gender issues in youth suicidal behaviour". Emergency Medicine Australasia. 14 (1): 35–42. doi:10.1046/j.1442-2026.2002.00283.x. ISSN 1742-6731.
  19. ↑ Morrison, Linda L.; Downey, Deborah L. (2000). "Racial differences in self-disclosure of suicidal ideation and reasons for living: Implications for training". Cultural Diversity and Ethnic Minority Psychology. 6 (4): 374–386. doi:10.1037/1099-9809.6.4.374. ISSN 1939-0106.
  20. ↑ Nestor, Bridget A.; Cheek, Shayna M.; Liu, Richard T. (2016). "Ethnic and racial differences in mental health service utilization for suicidal ideation and behavior in a nationally representative sample of adolescents". Journal of Affective Disorders. 202: 197–202. doi:10.1016/j.jad.2016.05.021. ISSN 0165-0327.
  21. ↑ 21.0 21.1 Gliatto MF, Rai AK (1999). "Evaluation and treatment of patients with suicidal ideation". Am Fam Physician. 59 (6): 1500–6. PMID 10193592.
  22. ↑ Gupta MA, Schork NJ, Gupta AK, Kirkby S, Ellis CN (1993). "Suicidal ideation in psoriasis". Int J Dermatol. 32 (3): 188–90. doi:10.1111/j.1365-4362.1993.tb02790.x. PMID 8444530.
  23. ↑ Meltzer H, Bebbington P, Brugha T, Jenkins R, McManus S, Dennis MS (2011). "Personal debt and suicidal ideation". Psychol Med. 41 (4): 771–8. doi:10.1017/S0033291710001261. PMID 20550757.
  24. ↑ Jones, Jana E; Hermann, Bruce P; Barry, John J; Gilliam, Frank G; Kanner, Andres M; Meador, Kimford J (2003). "Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy". Epilepsy & Behavior. 4: 31–38. doi:10.1016/j.yebeh.2003.08.019. ISSN 1525-5050.
  25. ↑ Wintersteen, M. B. (2010). "Standardized Screening for Suicidal Adolescents in Primary Care". PEDIATRICS. 125 (5): 938–944. doi:10.1542/peds.2009-2458. ISSN 0031-4005.
  26. ↑ Cochrane-Brink, Kate A; Lofchy, Jodi S; Sakinofsky, Isaac (2000). "Clinical rating scales in suicide risk assessment". General Hospital Psychiatry. 22 (6): 445–451. doi:10.1016/S0163-8343(00)00106-7. ISSN 0163-8343.
  27. ↑ Desseilles, Martin; Perroud, Nader; Guillaume, Sébastien; Jaussent, Isabelle; Genty, Catherine; Malafosse, Alain; Courtet, Philippe (2012). "Is it valid to measure suicidal ideation by depression rating scales?". Journal of Affective Disorders. 136 (3): 398–404. doi:10.1016/j.jad.2011.11.013. ISSN 0165-0327.
  28. ↑ Mundt, James C.; Greist, John H.; Gelenberg, Alan J.; Katzelnick, David J.; Jefferson, James W.; Modell, Jack G. (2010). "Feasibility and validation of a computer-automated Columbia-Suicide severity rating scale using interactive voice response technology". Journal of Psychiatric Research. 44 (16): 1224–1228. doi:10.1016/j.jpsychires.2010.04.025. ISSN 0022-3956.
  29. ↑ Abe, Takeru; Runeson, Bo; Odeberg, Jenny; Pettersson, Agneta; Edbom, Tobias; Jildevik Adamsson, Ingalill; Waern, Margda (2017). "Instruments for the assessment of suicide risk: A systematic review evaluating the certainty of the evidence". PLOS ONE. 12 (7): e0180292. doi:10.1371/journal.pone.0180292. ISSN 1932-6203.
  30. ↑ Gutierrez, Peter M.; Osman, Augustine; Kopper, Beverly A.; Barrios, Francisco X.; Bagge, Courtney L. (2000). "Suicide risk assessment in a college student population". Journal of Counseling Psychology. 47 (4): 403–413. doi:10.1037/0022-0167.47.4.403. ISSN 1939-2168.
  31. ↑ Roberts, Robert K.; Roberts, Catherine R.; Chen, Y. Richard (1998). "Suicidal Thinking Among Adolescents With a History of Attempted Suicide". Journal of the American Academy of Child & Adolescent Psychiatry. 37 (12): 1294–1300. doi:10.1097/00004583-199812000-00013. ISSN 0890-8567.
  32. ↑ Alexopoulos, George S.; Bruce, Martha L.; Hull, James; Sirey, Jo Anne; Kakuma, Tatsuyuki (1999). "Clinical Determinants of Suicidal Ideation and Behavior in Geriatric Depression". Archives of General Psychiatry. 56 (11): 1048. doi:10.1001/archpsyc.56.11.1048. ISSN 0003-990X.
  33. ↑ Chochinov, Harvey Max; Wilson, Keith G.; Enns, Murray; Lander, Sheila (1998). "Depression, Hopelessness, and Suicidal Ideation in the Terminally Ill". Psychosomatics. 39 (4): 366–370. doi:10.1016/S0033-3182(98)71325-8. ISSN 0033-3182.
  34. ↑ Milos, Gabriella; Spindler, Anja; Hepp, Urs; Schnyder, Ulrich (2004). "Suicide attempts and suicidal ideation: links with psychiatric comorbidity in eating disorder subjects". General Hospital Psychiatry. 26 (2): 129–135. doi:10.1016/j.genhosppsych.2003.10.005. ISSN 0163-8343.
  35. ↑ Miranda, Regina; Ortin, Ana; Scott, Michelle; Shaffer, David (2014). "Characteristics of suicidal ideation that predict the transition to future suicide attempts in adolescents". Journal of Child Psychology and Psychiatry. 55 (11): 1288–1296. doi:10.1111/jcpp.12245. ISSN 0021-9630.
  36. ↑ Borges, Lauren M.; Nazem, Sarra; Matarazzo, Bridget B.; Barnes, Sean M.; Wortzel, Hal S. (2019). "Therapeutic Risk Management". Journal of Psychiatric Practice. 25 (1): 46–53. doi:10.1097/PRA.0000000000000358. ISSN 1538-1145.
  37. ↑ Okolie, Chukwudi; Dennis, Michael; Simon Thomas, Emily; John, Ann (2017). "A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people". International Psychogeriatrics. 29 (11): 1801–1824. doi:10.1017/S1041610217001430. ISSN 1041-6102.
  38. ↑ Unützer, Jürgen; Tang, Lingqi; Oishi, Sabine; Katon, Wayne; Williams, John W.; Hunkeler, Enid; Hendrie, Hugh; Lin, Elizabeth H.B.; Levine, Stuart; Grypma, Lydia; Steffens, David C.; Fields, Julie; Langston, Christopher (2006). "Reducing Suicidal Ideation in Depressed Older Primary Care Patients". Journal of the American Geriatrics Society. 54 (10): 1550–1556. doi:10.1111/j.1532-5415.2006.00882.x. ISSN 0002-8614.
  39. ↑ Alexopoulos, George S.; Reynolds, Charles F.; Bruce, Martha L.; Katz, Ira R.; Raue, Patrick J.; Mulsant, Benoit H.; Oslin, David W.; Ten Have, Thomas (2009). "Reducing Suicidal Ideation and Depression in Older Primary Care Patients: 24-Month Outcomes of the PROSPECT Study". American Journal of Psychiatry. 166 (8): 882–890. doi:10.1176/appi.ajp.2009.08121779. ISSN 0002-953X.
  40. ↑ Gibbons, Robert D.; Brown, C. Hendricks; Hur, Kwan; Marcus, Sue M.; Bhaumik, Dulal K.; Erkens, Joëlle A.; Herings, Ron M.C.; Mann, J. John (2007). "Early Evidence on the Effects of Regulators' Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents". American Journal of Psychiatry. 164 (9): 1356–1363. doi:10.1176/appi.ajp.2007.07030454. ISSN 0002-953X.
  41. ↑ Singh T, Prakash A, Rais T, Kumari N (2009). "Decreased Use of Antidepressants in Youth After US Food and Drug Administration Black Box Warning". Psychiatry (Edgmont). 6 (10): 30–4. PMC 2790401. PMID 20011576.
  42. ↑ Tondo, Leonardo; Baldessarini, Ross J. (2016). "Suicidal Behavior in Mood Disorders: Response to Pharmacological Treatment". Current Psychiatry Reports. 18 (9). doi:10.1007/s11920-016-0715-0. ISSN 1523-3812.
  43. ↑ DiazGranados, Nancy; Ibrahim, Lobna A.; Brutsche, Nancy E.; Ameli, Rezvan; Henter, Ioline D.; Luckenbaugh, David A.; Machado-Vieira, Rodrigo; Zarate, Carlos A. (2010). "Rapid Resolution of Suicidal Ideation After a Single Infusion of anN-Methyl-D-Aspartate Antagonist in Patients With Treatment-Resistant Major Depressive Disorder". The Journal of Clinical Psychiatry. 71 (12): 1605–1611. doi:10.4088/JCP.09m05327blu. ISSN 0160-6689.
  44. ↑ Yovell, Yoram; Bar, Gali; Mashiah, Moti; Baruch, Yehuda; Briskman, Irina; Asherov, Jack; Lotan, Amit; Rigbi, Amihai; Panksepp, Jaak (2016). "Ultra-Low-Dose Buprenorphine as a Time-Limited Treatment for Severe Suicidal Ideation: A Randomized Controlled Trial". American Journal of Psychiatry. 173 (5): 491–498. doi:10.1176/appi.ajp.2015.15040535. ISSN 0002-953X.
  45. ↑ Bateman, Katy; Hansen, Lars; Turkington, Douglas; Kingdon, David (2007). "Cognitive Behavioral Therapy Reduces Suicidal Ideation in Schizophrenia: Results from a Randomized Controlled Trial". Suicide and Life-Threatening Behavior. 37 (3): 284–290. doi:10.1521/suli.2007.37.3.284. ISSN 0363-0234.
  46. ↑ Ducasse, Déborah; Jaussent, Isabelle; Arpon-Brand, Véronique; Vienot, Marina; Laglaoui, Camelia; Béziat, Séverine; Calati, Raffaella; Carrière, Isabelle; Guillaume, Sébastien; Courtet, Philippe; Olié, Emilie (2018). "Acceptance and Commitment Therapy for the Management of Suicidal Patients: A Randomized Controlled Trial". Psychotherapy and Psychosomatics. 87 (4): 211–222. doi:10.1159/000488715. ISSN 0033-3190.
  47. ↑ Diamond, Guy S.; Wintersteen, Matthew B.; Brown, Gregory K.; Diamond, Gary M.; Gallop, Robert; Shelef, Karni; Levy, Suzanne (2010). "Attachment-Based Family Therapy for Adolescents with Suicidal Ideation: A Randomized Controlled Trial". Journal of the American Academy of Child & Adolescent Psychiatry. 49 (2): 122–131. doi:10.1016/j.jaac.2009.11.002. ISSN 0890-8567.
  48. ↑ Tang, Tze-Chun; Jou, Shaw-Hwa; Ko, Chih-Hung; Huang, Shih-Yin; Yen, Cheng-Fang (2009). "Randomized study of school-based intensive interpersonal psychotherapy for depressed adolescents with suicidal risk and parasuicide behaviors". Psychiatry and Clinical Neurosciences. 63 (4): 463–470. doi:10.1111/j.1440-1819.2009.01991.x. ISSN 1323-1316.
  49. ↑ Gustavson, Kristen A.; Alexopoulos, George S.; Niu, Grace C.; McCulloch, Charles; Meade, Tanya; Areán, Patricia A. (2016). "Problem-Solving Therapy Reduces Suicidal Ideation In Depressed Older Adults with Executive Dysfunction". The American Journal of Geriatric Psychiatry. 24 (1): 11–17. doi:10.1016/j.jagp.2015.07.010. ISSN 1064-7481.
  50. ↑ Horowitz L, Tipton MV, Pao M (2020). "Primary and Secondary Prevention of Youth Suicide". Pediatrics. 145 (Suppl 2): S195–S203. doi:10.1542/peds.2019-2056H. PMID 32358211 Check |pmid= value (help).
  51. ↑ Williams, J Mark G; Pollock, Leslie R (2009). "Factors mediating suicidal behaviour: Their utility in primary and secondary prevention". Journal of Mental Health. 2 (1): 3–26. doi:10.3109/09638239309016951. ISSN 0963-8237.
  52. ↑ Ganz, Debora; Braquehais, M. Dolores; Sher, Leo (2010). "Secondary Prevention of Suicide". PLoS Medicine. 7 (6): e1000271. doi:10.1371/journal.pmed.1000271. ISSN 1549-1676.
  53. ↑ Farré, Adriana; Portella, Maria J.; De Angel, Luis; Díaz, Ana; de Diego-Adeliño, Javier; Vegué, Joan; Duran-Sindreu, Santiago; Faus, Gustavo; Tejedor, Carmen; Álvarez, Enric; Pérez, Víctor (2016). "Benefits of a Secondary Prevention Program in Suicide". Crisis. 37 (4): 281–289. doi:10.1027/0227-5910/a000388. ISSN 0227-5910.


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