Suicide is a common and profoundly serious problem, both in patients with identified psychiatric conditions and in people with no previously identified psychiatric disease. Suicide accounts for more than 30,000 deaths per year or 12:1,000 in the general population. But in certain age groups and at-risk groups, the numbers are much higher: Among adolescents and young adults, suicide rates have risen dramatically over the past four decades and now represent the second leading cause of death. Suicide rates climb with age, peaking for women in the seventh decade but continuing to rise steadily for men; hence, elderly men are at four times the risk of the general population, and 25% of all suicides occur in people older than 65 years. Long considered to predominate among whites, with suicide rates for nonwhites approximately half of that of whites, suicide rates have been increasing dramatically among young black men over the past 30 years. Native Americans experience the highest rates among American ethnic groups. Among the elderly and among people with several risk factors, such as chronic illness, social isolation, and substance abuse, suicide is a leading cause of death.

Suicide is also an eminently preventable cause of death. It is estimated that as many as 90% of the people who do complete suicide may have a treatable psychiatric disorder, such as depression. The identification and treatment of these individuals are urgent.

Not all self-harm is suicidal in intent. Many patients engage in deliberate self-injurious behavior, not to kill themselves but to soothe intolerable psychic pain. Such behavior, which may include cutting, burning with cigarettes, or other autoerotic painful behavior, is commonly seen in individuals suffering from posttraumatic stress disorder and among victims of sexual abuse. The management of selfinjurious behavior is different from that of suicidal behavior.

Many times people conceal their suicidal intentions or the severity of their suicidal wishes. Particularly because suicide is often driven by feelings of shame and inadequacy, it is understandable that many people find these feelings difficult to share with strangers, such as emergency department (ED) personnel.

The ED itself is often not conducive to an effective evaluation of patients at risk for suicide. Noise, intrusions by others, urgency and lack of time, and inadequate privacy make the elicitation and evaluation of subtle or inapparent suicidal intentions very difficult.

Often, people who attempt suicide or who harbor self-destructive tendencies elicit negative reactions in caregivers. These feelings may range from aversion and hostility to overinvolvement and inappropriate rescue actions. These feelings may stem in part from the common experience that many people who come or are brought to the ED following a suicide “attempt” have not really tried to kill themselves; instead, their behavior appears more “manipulative” in an attempt to influence the behavior of others. In a crowded ED filled with people who did nothing to contribute to their suffering or illness, there is a great temptation to blame the person with suicidal behavior. If the practitioner is not aware of these feelings toward the suicidal patient, then he or she runs the risk of expressing them in the treatment of the patient. Such acting out of the doctor’s feelings can be manifested as curt treatment, minimizing the patient’s difficulties and not appreciating the real risk of death from suicide in the future, particularly if the patient senses that he or she must “up the ante” to be taken seriously.

Despite the fact that we can identify numerous risk factors (see “Risk Factors”) for completed suicide, there is no absolutely reliable way to predict who will complete suicide. Therefore, we rely on the clinical guidelines outlined here, but we understand the reality that we may underestimate the suicide risk in any given individual.

Take all suicide attempts seriously.

Consider occult suicide in all patients who fit high-risk profiles (see “Risk Factors”).

Take enough time and create an adequate space to conduct the evaluation.

When appropriate, involve outside caregivers, family, and other people in the person’s life.

Seek consultation appropriately.

Document clearly and carefully.

The disposition of the person who has been evaluated for suicide must assure his or her safety reasonably, account for the possibility that his or her suicidal tendencies might increase after the completion of the evaluation, and plan accordingly.

Therefore, everyone in whom suicide is considered even a remote possibility should have a future contact planned with a professional and/or a clear plan and method for accessing help in an emergency.