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Background: STOP Project

General Information: Suicidality

Suicidality refers to suicidal ideation and suicide-related behaviors including completed suicide. Suicidal ideation comprises thoughts related to suicide and suicide plans. Suicide related behaviors include completed suicide (self-inflicted death with intention to die), suicidal attempts (self-inflicted potentially harmful behavior without fatal issue but with intention to die), self harm (deliberate self-inflicted potentially harmful act regardless of motive). The term of deliberate self harm refers to self-inflicted injuries regardless of the intent to die. In the UK, the term has been changed to “self-harm” to avoid the connotation of intentionality (however, in the US literature, the term self-harm qualifies intentional injuries without intent to die e.g. “self-mutilation”). A suicide threat is the communication of a suicidal intent whereas a suicide plan is a concrete suicide project.

Suicide is one of the tenth leading cause for deaths worldwide (7), contributing 1.5% of all deaths. Approximately 1 million people die due to suicide each year, (19, 20).

Risk of suicidal ideation increases rapidly during adolescence and young adulthood and stabilizes in early midlife (9). The greatest risk for suicidal attempts is in adolescence and early adulthood. The prevalence rates in adolescents are reported cross-nationally to be 19.8-24.0% for suicidal ideation, and 3.1% - 8.8% for suicidal attempts (9).

Suicide is the second cause of death among young people, after accidents. The rates of suicide vary according to age; in childhood and early adolescence suicide is rare but suicide rates increase in adolescents and young adulthood. The latest mean worldwide annual rates of suicide per 100 000 were 0.5 for females and 0.9 for males among 5-14-year-olds, and 12.0 for females and 14.2 for males among 15-24-year-olds, respectively (12). Males often outnumber females in worldwide youth completed suicide statistics, although suicide attempts are more frequent in females.

Due to the growing risk for suicide with increasing age, adolescents are the main target of suicide prevention as less than half of young people who have committed suicide had received psychiatric care.

Are suicidal ideation, attempts and completed suicide related?

Suicidal ideation and behaviours can occur both independently and together. The majority of individuals who report suicidal ideation will not try to commit suicide (2). Research across 17 countries has suggested that those who have suicidal ideations have the conditional probability of 29% of ever making a suicide attempt (10). However, attempt increases to 56% for those who do have suicidal ideation and have formulated a plan, but without this plan only 15.4% are likely to attempt suicide (10). The majority of these transitions will occur within the first year of the onset of suicidal ideation (9).

In patients having attempted suicide, 24,5 % will commit another suicidal attempt in the next seven years (4). The risk of suicide in the year following a suicidal attempt is 30 to 200 times higher in comparison with the general population and increases with the number of suicidal attempts, particularly in women (5, 6).

Is self-harm related to suicidality?

The progression from suicidal ideation to self-harm and then to suicide is by no means absolute. However of those patients who present to hospital with self-harm, around 7% will have completed suicide over a 9 year period of follow-up (11). The suicide rate appears to be higher amongst those patients who abscond from medical care or who took precautions against discovery (1, 15).

What are the main risk factors of suicidality?

Primary risk factors are associated with high individual risk and are likely targets for therapeutic interventions. Main primary risk factors are : familial and personal antecedents of suicidal behavior, presence of a psychiatric disorder (mainly depressive disorders and disruptive behaviors), substance use such as repeated acute alcohol intake , the communication of suicidal intent, high impulsivity, high hopelessness (sub-clinical depressive symptoms), presence of a chronic physical illness. Secondary risk factors are identified in the community and are only partially modifiable; they comprise early loss of a parent, social isolation, unemployment or financial problems, severe adverse life events, being actor or victim of violence. Tertiary risk factors are statistically associated with suicidal risk but carry a low individual predictive value: age (adolescence and old age), male gender, vulnerability periods (summer, premenstrual period in women).

Assessment of suicidality in general

Patients presenting with suicidal ideation or following a suicide attempt should be assessed at three levels: presence of risk factors, immediacy of suicidal risk and dangerousness of the suicidal means. The immediacy of suicidal risk involves the existence of a suicidal scenario and is rated high if the suicidal plan is precise and concrete, moderate if the plan is imprecise and low in the absence of a scenario. The absence of alternative for the patient also contributes to the immediacy of risk. Assessment of suicidal means refers to lethality and accessibility of the considered suicide method. Suicidality is generally assessed through clinical interview, eventually completed by questionnaires.

Screening procedures have been developed to identify at-risk children and adolescents in order to offer prevention services. These include self-report measures such as the Columbia Suicide Screen (13), the Suicide Risk Screen and the Suicidal Ideation Questionnaire – Junior (SIQ-Jr) (16). Universal screening in school settings for example carry the risk of identifying false positives and the issue of follow-up of subjects with positive screens; screening in at-risk groups (children/adolescents in emergency departments, in primary care) is an important issue that also calls for outcome assessments.

What is medication-related suicidality?

The term ‘Medication-Related Suicidality’ (MRS) is a reported adverse event and is defined as any suicide-related symptoms that are reported during the period of treatment with the drug. Symptoms include suicidal ideation, suicidal plans and suicidal behaviours and sometimes also extend to non-suicidal self-harm.

What are the mechanisms of medication-related suicidality?

The mechanisms involved in increased suicidal ideation and behaviour during treatment are unknown. It has been proposed that medication may induce behavioural activation, including anxiety, irritability, agitation, and insomnia, which would facilitate suicidality, presumably mainly in the first weeks of treatment. Analyses of community clinical practice databases show conflicting results: some have indeed indicated that the rate of suicidal behaviour is highest in the first month of treatment, and especially during the first nine days (8) but in other analyses the rate was actually the highest in the month prior to starting antidepressant medication with a gradual decline during treatment (3). Time patterns of suicide attempts in clinical populations show highest rates of suicide attempts in the month before treatment and next highest in the month after starting treatment and decrease afterwards; these time patterns have been shown in adult outpatients with both medications and psychotherapy. Most suicidal events in the antidepressant trials conducted in children and adolescents occurred in the context of persistent depression and insufficient improvement, without evidence of medication-induced behavioral activation as a precursor (19).

How can medication-related suicidality be assessed?

Assessment of suicidality in relation to drugs is difficult in particular in children and adolescents because of a number of reasons: 1) Assessment procedures of suicidality developed in adults may not be appropriate for younger people (e.g. differences in self-assessment, ability to communicate emotions, abstract thinking) 2) Suicidality related to pharmacological treatment may be different from suicidality related to disease. 3) Notification and recording of suicidality is variable across clinical trials.

What are the expected improvements in assessing MRS with the STOP project?

It is the aim of the STOP project to create a multidimensional assessment and monitoring tool to detect and follow-up suicidal ideas and behaviors that could be implemented in clinical practice and in clinical trials. This assessment will be based on two classifications: the classification of suicide related thoughts and behavior (17) and the Columbia Classification Algorithm of suicidal assessment (C-CASA) (14). The output of the STOP assessment is a computer generated classification of suicidality. This comprehensive assessment of suicidality and related individual and environmental variables (moderators and mediators of suicidality) will contribute to a better understanding of the specific characteristics of medication-related suicidality. Once standardized, the STOP classification could be used for pharmacovigilance and in epidemiological, observational and registration trials.