Case 10 – A 47-year-old man with suicidal ideation

A 47-year-old man was diagnosed with AIDS 3 years ago. Shortly after his diagnosis, he informed his partner of 8 years over the phone; she subsequently hung up on him and refused to speak with him again. Since then he had become progressively more socially isolated from his friends and family and had started drinking heavily. The pain from his peripheral neuropathy is a source of constant agony. On several occasions he has expressed a desire to die to his physician, and against the doctor’s pleas he has stopped taking his antiretroviral medications. He refuses to seek help from a psychiatrist who could treat his depression and help him to cope with his illness. He views his illness as a punishment and sees no good in trying to delay the inevitable. He feels useless and beyond help.

What is the epidemiology of suicide in the United States?

The annual death rate from suicide is higher than the annual death rate from homicide. Suicide is the eighth leading cause of death for adults and the second leading cause of death for college students. Nearly 30,000 suicides occur each year; roughly 1% of the U.S. population commits suicide. For every completed suicide, there are 18 failed attempts. For men, suicides occur more frequently as they age, with a peak at age 75 years; for women, the suicide rate peaks at 40-50 years. Men who commit suicide are most likely to be >45 years old, white, and either separated, divorced, or widowed. Women are more likely to attempt suicide; men are more likely to complete the act. Most people who commit suicide communicate their suicidal intentions to their physician and see their physicians before they die. Research indicates that more than 90% of those who commit suicide have a major psychiatric illness and half are clinically depressed at the time of the act.

What is the relationship between illness and suicide?

Nearly 5% of people who commit suicide have been diagnosed with a serious physical illness. Suicide rates are high among those diagnosed with AIDS, amyotrophic lateral sclerosis, Huntington’s disease, traumatic brain injuries, epilepsy, multiple sclerosis, Parkinson’s disease, and cancer. The suicide rate in patients with AIDS is nearly seven times greater than that in the general population. In many of these medical conditions, pain is often a mitigating factor.

What assessment tools are helpful in identifying suicide risk?

The following mnemonic SAD PERSONS is helpful to remember when assessing patients for suicide risk:

1. Sex (male gender)
2. Age (older)
3. Depression
4. Previous suicide attempt
5. Ethanol abuse
6. Rational thinking loss
7. Social support lacking
8. Organized plan
9. No spouse or partner
10. Sickness

Specific questions that should be asked of a person at risk for committing suicide ought to be direct and give the patient an opportunity to discuss his or her intentions. They include:

1. Have you been feeling like life is not worth living?
2. Have you been having thoughts of harming yourself?
3. Have you developed a plan for taking your life?
4. Do you have access to a weapon or means to commit the act?

By Kristen Vierregger, University of Pennsylvania School of Medicine, Class of 2008; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.