Previous Suicidal Behavior Research Articles

Feasibility of Screening Patients With Nonpsychiatric Complaints for Suicide Risk in a Pediatric Emergency Department

Screening children for suicide risk when they present to the emergency department (ED) with nonpsychiatric complaints could lead to better identification and treatment of high-risk youth. Before suicide screening protocols can be implemented for nonpsychiatric patients in pediatric EDs, it is essential to determine whether such efforts are feasible. As part of an instrument validation study, ED patients (10-21 years old) with both psychiatric and nonpsychiatric presenting complaints were recruited to take part in suicide screening. Clinically significant suicidal thoughts, as measured by the Suicidal Ideation Questionnaire, and suicidal behaviors were assessed, as well as patient opinions about suicide screening. Recruitment rates for the study as well as impact on length of stay were assessed. Of the 266 patients and parents approached for the study, 159 (60%) agreed to participate. For patients entering the ED for nonpsychiatric reasons (n = 106), 5.7% (n = 6) reported previous suicidal behavior, and 5.7% (n = 6) reported clinically significant suicidal ideation. There were no significant differences for mean length of stay in the ED for nonpsychiatric patients with positive triggers and those who screened negative (means, 382 [SD, 198] and 393 [SD, 166] minutes, respectively; P = 0.80). Ninety-six percent of participants agreed that suicide screening should occur in the ED. Suicide screening of nonpsychiatric patients in the ED is feasible in terms of acceptability to parents, prevalence of suicidal thoughts and behaviors, practicality to ED flow, and patient opinion. Future endeavors should address brief screening tools validated on nonpsychiatric populations.

Comparison of characteristics of suicide attempters with schizophrenia spectrum disorders and those with mood disorders in Japan

Suicidality in patients with schizophrenia is high. To clarify the characteristics of suicidal behavior in patients with schizophrenia, we investigated suicide attempters with schizophrenia spectrum disorders in comparison with patients with mood disorders. One hundred patients with schizophrenia spectrum disorders and 155 patients with mood disorders admitted to an emergency department after a suicide attempt were interviewed in detail on items concerning 1) demographic characteristics, 2) previous suicidal behavior, and 3) index suicidal behavior. Differences between the two groups were subsequently analyzed. Patients with schizophrenia spectrum disorders showed a lower incidence of previous deliberate self-harm, and a higher incidence of a subsequent suicide attempt more than 1 year after the previous suicide attempt as well as a higher lethality of index suicide attempt compared to patients with mood disorders. Furthermore, the most common motive for making a suicide attempt in patients with schizophrenia spectrum disorders was having a mental problem. This study revealed the factors associated with suicide attempts among Japanese patients with schizophrenia spectrum disorders, and the nature of these factors makes it difficult to predict future attempts. This makes clear the importance of continuous long-term follow-up with careful attention to the mental symptoms and psychological burden for such patients.

Suicide Inside

The literature on inpatient suicides was systematically reviewed. English, German, and Dutch articles were identified by means of the electronic databases PsycInfo, Cochrane, Medline, EMBASE psychiatry, CINAHL, and British Nursing Index. In total, 98 articles covering almost 15,000 suicides were reviewed and analyzed. Rates and demographic features connected to suicides varied substantially between articles, suggesting distinct subgroups of patients committing suicide (e.g., depressed vs. schizophrenic patients) with their own suicide determinants and patterns. Early in the admission is clearly a high-risk period for suicide, but risk declines more slowly for patients with schizophrenia. Suicide rates were found to be associated with admission numbers, and as expected, previous suicidal behavior was found to be a robust predictor of future suicide. The methods used for suicide are linked to availability of means. Timing and location of suicides seem to be associated with absence of support, supervision, and the presence of family conflict. Although there is a strong notion that suicides cluster in time, clear statistical evidence for this is lacking. For prevention of suicides, staff need to engage with patients' family problems, and reduce absconding without locking the door. Future research should take into account the heterogeneous subgroups of patients who commit suicide, with case-control studies addressing these separately.

Suicidality among Norwegian youth: Review of research on risk factors and interventions

Background and Aim: Published research on suicidality among Norwegian youth and publications describing interventions were summarized in order to access the current status of knowledge building via empirical research. Method: A systematic Medline search identified 29 studies on risk factors on the entire spectrum of suicidal phenomena from self-harm without suicidal ideation to completed suicide with the mean age at/under 25 years. A specialist Norwegian journal, Suicidologi, was searched for additional matter, especially interventions. Result: Most studies focussed on psychological and psychiatric risk factors of attempted suicide. Other suicidal phenomena, psychosocial and societal risk factors, and impact of interventions were hardly studied. Depression, previous suicidal behaviour, alcohol use and non-intact parental unit were consistent significant risk factors found in suicide and attempted suicide studies. Conclusion: Supporting non-intact parental units and the maintenance of intact parental units along with early detection and management of suicide attempts, depression and alcohol use should be targeted as suicide prevention interventions among adolescents.

A population-based longitudinal study of risk factors for suicide attempts in major depressive disorder

No longitudinal study has examined risk factors for future suicide attempts in major depressive disorder in a nationally representative sample. The objective of this study was to investigate baseline sociodemographic characteristics, comorbid mental disorders, specific depressive symptoms, and previous suicidal behavior as potential risk factors for suicide attempts at 3 years follow-up. Data came from the national epidemiologic survey on alcohol and related conditions (NESARC), a large nationally representative longitudinal survey of mental illness in adults [Wave 1 (2001–2002); Wave 2 (2004–2005) n = 34,653]. Logistic regression examined associations between risk factors present at Wave 1 and suicide attempts at Wave 2 ( n = 169) among individuals with major depressive disorder at baseline assessment ( n = 6004). Risk factors for incident suicide attempts at Wave 2 ( n = 63) were identified among those with major depressive disorder at Wave 1 and no lifetime history of suicide attempts ( n = 5170). Results revealed specific comorbid anxiety, personality, and substance use disorders to be associated with incident suicide attempts at Wave 2. Comorbid borderline personality disorder was strongly associated with suicide attempts in all models. Several comorbid disorders were strongly associated with suicide attempts at Wave 2 even after adjusting for previous suicidal behavior, notably posttraumatic stress disorder (adjusted odds ratio (AOR) = 2.20; 95% confidence interval (95% CI) 1.27–3.83) and dependent personality disorder (AOR = 4.43; 95% CI 1.93–10.18). These findings suggest that mental illness comorbidity confers an increased risk of future suicide attempts in major depressive disorder that is not solely accounted for by past suicidal behavior.

Suicide attempts prior to starting methadone maintenance treatment in Taiwan

This study investigates recent (one-month) and lifetime prevalence of suicide attempts, and factors associated with one-month suicide attempts among heroin users ( n = 488) seeking treatment at a methadone maintenance programme in Taiwan. Data were collected by structured interview on demographics, use of heroin and other substances, criminal convictions, depression, social networks, and history of suicide attempt (lifetime suicide attempt, and suicide attempt and suicide ideation in the previous month). Prevalence of recent (one-month) suicide attempt was 10.9% and lifetime prevalence was 17.8%. The finding that so many heroin users had made a suicide attempt in the very recent past is both disturbing and little researched. Recent suicidal attempts were associated with severity of heroin dependence, needle sharing, higher educational level, increased levels of depression, and number of stressful life events. It is suggested that methadone maintenance programmes should routinely screen at intake for previous suicidal behaviour and especially for recent suicidal attempts.

Tetrabenazine as anti-chorea therapy in Huntington Disease: an open-label continuation study. Huntington Study Group/TETRA-HD Investigators

BackgroundTetrabenazine (TBZ) selectively depletes central monoamines by reversibly binding to the type-2 vesicular monoamine transporter. A previous double blind study in Huntington disease (HD) demonstrated that TBZ effectively suppressed chorea, with a favorable short-term safety profile (Neurology 2006;66:366-372). The objective of this study was to assess the long-term safety and effectiveness of TBZ for chorea in HD.MethodsSubjects who completed the 13-week, double blind protocol were invited to participate in this open label extension study for up to 80 weeks. Subjects were titrated to the best individual dose or a maximum of 200 mg/day. Chorea was assessed using the Total Maximal Chorea (TMC) score from the Unified Huntington Disease Rating Scale.ResultsOf the 75 participants, 45 subjects completed 80 weeks. Three participants terminated due to adverse events (AEs) including depression, delusions with associated previous suicidal behavior, and vocal tics. One subject died due to breast cancer. The other 26 subjects chose not to continue on with each ensuing extension for various reasons. When mild and unrelated AEs were excluded, the most commonly reported AEs (number of subjects) were sedation/somnolence (18), depressed mood (17), anxiety (13), insomnia (10), and akathisia (9). Parkinsonism and dysphagia scores were significantly increased at week 80 compared to baseline. At week 80, chorea had significantly improved from baseline with a mean reduction in the TMC score of 4.6 (SD 5.5) units. The mean dosage at week 80 was 63.4 mg (range 12.5-175 mg).ConclusionsTBZ effectively suppresses HD-related chorea for up to 80 weeks. Patients treated chronically with TBZ should be monitored for parkinsonism, dysphagia and other side effects including sleep disturbance, depression, anxiety, and akathisia.Trial RegistrationClinicaltrials.gov registration number (initial study): NCT00219804

Selective Serotonin Reuptake Inhibitors and Suicidality: A Guide for the Perplexed

Can J Psychiatry. 2009;54(2):72-74. The rate of suicidal adverse events is elevated around 2-fold in drugs, relative to placeboes, in clinical trials of antidepressants in children, adolescents, and young adults.1,2 Since the FDA's black box warning in 2003-2004, there has been a decline in the prescription rate of antidepressants, with no compensatory increase in referrals for psychotherapy in the United States.3 Families, patients, and clinicians are uncertain about how to balance the benefits and risks of antidepressants. In this brief review, the clinical significance of suicidal events is discussed along with the factors that may increase or attenuate the risk, possible explanations for this phenomenom, the benefits and risks of antidepressants, the public health implications of a decline in the use of SSRIs, and recommendations for clinicians. Suicidal adverse events are treatment-emergent increases in suicidal ideation or an actual suicide attempt. In more than 4300 participants in pediatric antidepressant clinical trials, there have been no deaths by suicide, and most of these events were increases in suicidal ideation, rather than actual suicide attempts. The actual risk difference for the occurrence of an event is not large. While the FDA initially reported a risk difference of 2%, a more recent re-analysis included more recently conducted trials found a risk difference of only 0.9%, which translates to a NNH of 121.1,2 Moreover, during the period of time when the rate of SSRI prescriptions was increasing, youth suicide rates were declining.4 One cannot necessarily infer a causal relation between the increase in the use of SSRIs in adolescents and a decline in the adolescent suicide rate. However, if antidepressants were associated with an increased risk for suicide, one would have expected an increase in adolescent suicide, which clearly was not the case. The nature of assessment for suicidal events has also been questioned. In most clinical trials, suicidal events are not surveyed systematically, but are reported spontaneously. In fact, in the subset of clinical trials that had systematic assessment, there was no difference between medication and placebo regarding systematically assessed suicidal ideation.2 However, other reports have shown similar rates of events, whether using usual adverse event reporting methods or by deriving the occurrence of events from systematically assessed measures of self-reported suicidal ideation. 5'6 Predictors of suicidal adverse events include previous suicidal behaviour and higher baseline levels of suicidal ideation, anger, and irritability.5 In the Treatment of Adolescent Depression Study,6 the rate of suicidal events was lower in the combination of antidepressant and CBT than in medication alone; however, in other clinical trials of more severely or chronically depressed youth, no protective effect was found for combination treatment.6,7 No relation has been established among dosage, adherence pattern, medication type, and risk for events, and while some promising pharmacogenetic findings have been reported, there is currently no clinical applicability of these findings. Several hypotheses, all unproven, have been advanced to explain the increased rate of suicidal events in antidepressant-treated patients, compared with those on placebo. These have included induction of akathisia, disinhibition, increasing energy of the patient to the point where he or she can actually make an attempt, induction of mania or a mixed state, or withdrawal from medication as a result of nonadherence, with induction of dysphoria and suicidality. The adage of suicidal behaviour coming as a consequence of improvement in mood is not consistent with data showing a high correlation between severity of suicidal ideation and severity of depression; further, most reported suicidal events were not attempts, but were increases in suicidal ideation. The induction of a mixed state can certainly lead to suicidal ideation and behaviour; however, while the risk of a suicidal event is higher in adolescents than in children, the risk of mania after treatment with an antidepressant is higher in younger children. …

Substance use disorders and suicide attempts in bipolar subtypes

Bipolar disorder (BD) is associated with high rates of suicide attempt and completion. Substance use disorders (SUD) have been identified as potent risk factors for suicidal behavior in BD. However, little is known concerning differences between BD subtypes with regard to SUD as a risk factor for suicidal behavior. We studied previous suicidal behavior in adults with a major depressive episode in context of BD type I (BD-I; N = 96) or BD type II (BD-II; N = 42), with and without history of SUD. Logistic regressions assessed the association between SUD and suicide attempt history by BD type, and exploratory analyses examined the effects of other clinical characteristics on these relationships. SUD were associated with suicide attempt in BD-I but not BD-II, an effect not attributable to sample size differences. The higher suicide attempt rate associated with alcoholism in BD-I was mostly explained by higher aggression scores, and earlier age of BD onset increased the likelihood that alcohol use disorder would be associated with suicide attempt(s). The higher suicide attempt rate associated with other drug use disorders in BD-I was collectively explained by higher impulsivity, hostility, and aggression scores. The presence of both alcohol and drug use disorders increased odds of a history of suicide attempt in a multiplicative fashion: 97% of BD-I who had both co-morbid drug and alcohol use disorders had made a suicide attempt. A critical next question is how to target SUD and aggressive traits for prevention of suicidal behavior in BD-I.

Approche clinique du suicide au cours de la schizophrénie (I). Identification des facteurs de risque

Suicide is the leading cause of premature death in schizophrenia. Approximately 10 to 13% of deaths in schizophrenia are explained by suicide, despite widespread availability of generally effective antipsychotic treatments and suicide attempts have been reported among 20 to 50% of patients. This relatively low ratio of attempts/suicide is consistent with greater lethality of means - more violent - and intents - less ambivalence - in this population. Many studies have focused on risk factors and clinical characteristics for completed and/or attempted suicide. Commonly, sociodemographic risk factors for suicide are male sex, younger age and, among women, being unmarried, divorced or widowed. Previous suicidal behaviour is a strong risk factor for suicide and contrary to the common view, schizophrenic patients often communicate their suicidal intents shortly before death. Moreover, family history of suicide is associated with a heightened risk of suicide and is independent of the diagnosis, according to the growing literature that shows that vulnerability to suicidal behaviour is independent of psychiatric diagnosis. Suicide can occur throughout the entire course of schizophrenia. This is particularly true in those high-risk periods: early phase of the disease, active illness phase, period of relapse or during a depressive episode. The role of insight and positive symptoms remains unclear and probably needs further studies. Although not specifically for people with schizophrenia, hopelessness is a major risk factor and tragic loss is often presented as a trigger for suicide. It has been suggested that treatment side-effects, such as akathisia are associated with suicidal behaviour. A better knowledge of risk and protective factors is necessary to prevent suicide and suicidality.

Innovations: Accommodations: Efforts to Support Special-Needs Soldiers Serving in the Israeli Defense Forces

Innovations: Accommodations: Efforts to Support Special-Needs Soldiers Serving in the Israeli Defense Forces

Behind impulsive suicide attempts: Indications from a community study

Aim A considerable proportion of suicide attempts are made on impulse. However, knowledge of characteristics of impulsive attempters is still limited. The present study investigated some of these characteristics and aimed to identify the pattern (if any) of suicidal ideation before an impulsive attempt. Methods Data from a randomized and stratified population of 5130 individuals from Brisbane, Australia, were analysed. Computer-assisted telephone interviews (CATI) were adopted to recruit subjects. Those reporting previous suicidal behaviour were sent a questionnaire by mail. Results One hundred and twelve subjects reported a suicide attempt. One quarter of these described a pattern consistent with an impulsive attempt. Most impulsive attempters experienced suicidal thoughts before their attempt. They were less likely to believe that their attempt would cause death, and less likely to experience depression. Impulsive attempters did not differ significantly from non-impulsive attempters in regards to age, gender, and motivations for the attempt. Surprisingly, no differences in mean scores of trait impulsivity between impulsive and non-impulsive attempters were found. In addition, the majority of suicide attempters (whether impulsive or not) experienced the suicidal process as fluctuating and not as developing along a continuum. Limitations The number of attempters who validly entered the study limited our ability to identify potential confounders. Due to the retrospective nature of the survey, the reliability of the information collected may have been affected by recall biases. In addition, as the surveys were administered by mail, it is possible that some questions may have been misinterpreted. Conclusions The presence of suicidal feelings prior to an attempt constitutes an opportunity for intervention also in impulsive attempters. However, the identification of impulsiveness requires more research efforts.

The Repetition of Suicidal Behavior

To determine the proportion of individuals who repeated nonfatal suicidal behavior within 12 months of an index episode, to investigate the timing of repetition, and to investigate risk factors associated with repetition and their population impact. We carried out a prospective cohort study (1997-2002) in 4 large hospitals in North West England. We included subjects aged 15 years and over who attended with "self-harm" (an act of intentional self-poisoning or injury irrespective of the apparent purpose of the act). Following the episode, a standard assessment form, which included detailed demographic and clinical data, was completed by a clinician. 9213 individuals presented during the study period. The incidence of repetition within 12 months of the index episode was 13.6% (95% CI: 12.9% to 14.4%). The median time to first repetition was 73.5 days (interquartile range, 20 to 187 days). One in 10 subjects repeated within 5 days of the index episode. Independent risk factors for repetition included previous suicidal behavior, psychiatric treatment, being unemployed or registered sick, self-injury, alcohol misuse, and reporting suicidal plans or hallucinations at the time of the index episode. The combined population attributable fraction (an indicator of the potential population impact) for these variables was 65%. The repetition of suicidal behavior is common and occurs quickly. On a population level, our study suggests that the most important strategies to reduce repetition might include primary prevention of suicidal behavior, targeting psychiatric illness, and tackling social factors such as unemployment. Specific interventions may be required for individual subgroups.

Differences in characteristics between suicide victims who left notes or not

Background Suicide notes (SN) are one of markers of the severity of a suicide attempt and are said to provide a valuable insight into the thinking of suicide victims before the fatal act [Shah, A., De, T., 1998. Suicide and the elderly. Int. J. Psychiat. Clin Pract. 2, 3–18]. To examine whether suicide victims who wrote notes (note writers: NW) differ from those who did not, we investigated the characteristics of a sample of more than 5000 Japanese suicides using multiple logistic regression analysis. Methods For all suicide victims (5161 cases), we examined the following information: gender, age, suicide method, reason for suicide, marital status, residential status, history of psychiatric disorders, previous suicidal behavior, physical disease, and content of suicide notes. Results Mean incidence of NW was 30.1% (male: 29.7%, female: 30.8%). NW in Japan had the following characteristics; higher proportion in female and living alone, suicide by more lethal methods such as carbon monoxide, hanging or sharp instruments. On the other hand, non-NW had tendencies to commit suicide for reasons of physical illness and psychiatric disorder, and/or history of previous psychiatric disorders. Limitations This study is observational and discusses only completed, not attempted, suicide. Medical and psychiatric comorbidity are judged only by the history of diagnosis and the information about the problems in relationships is based not on valid criteria for inclusion. Conclusions Although these findings show ethnic differences, it is possible that SN may be considered an indicator of a serious suicide attempt. Further studies of SN are needed to confirm this.

Problem Solving Deteriorates Following Mood Challenge in Formerly Depressed Patients With a History of Suicidal Ideation.

The authors divided 34 participants who had a history of depression into 2 groups, those having previous suicidal ideation or behavior (n=19) and those having no such symptoms (n=15), then compared the 2 groups with a group of participants who had no history of depression (n=22). Assessment of interpersonal problem-solving performance using the Means-Ends Problem-Solving (MEPS) task before and after a mood-induction procedure showed that only those formerly depressed people with a history of suicidal ideation shifted in MEPS performance, producing significantly less effective problem solutions following mood challenge, consistent with a differential activation account of vulnerability for recurrence of suicidal ideation and behavior. The deterioration in effectiveness following mood challenge was moderated by lack of specificity in autobiographical memory.

Mental health and socio-economic variations in Australian suicide

This paper investigates the relationship between suicide rates and prevalence of mental disorder and suicide attempts, across socio-economic status (SES) groups based on area of residence. Australian suicide data (1996–1998) were analysed in conjunction with area-based prevalences of mental disorder derived from the National Survey of Mental Health and Well-Being (1997). Poisson regression models of suicide risk included age, quintile of area-based SES, urban–rural residence, and country of birth (COB), with males and females analysed separately. Analysis focussed on the association between suicide and prevalences of (ICD-10) affective disorders, anxiety disorders, substance use disorders and suicide attempts by SES group. Prevalences of other psychiatric symptomatology, substance use problems, health service utilisation, stressful life-events and personality were also investigated. Significant increasing gradients were evident from high to low SES groups for prevalences of affective disorders, anxiety disorders (females only), and substance use disorders (males only); sub-threshold drug and alcohol problems and depression; and suicide attempts and suicide (males only). Prevalences of mental disorder, other sub-threshold mental health items and suicide attempts were significantly associated with suicide, but in most cases associations were reduced in magnitude and became statistically non-significant after adjustment for COB, urban–rural residence, and SES. For male suicide the relative risk (RR) in the lowest SES group compared to the highest was 1.40 (95% CI 1.29–1.52, p < 0.001 ) for all ages, and 1.46 (95% CI 1.27–1.67, p < 0.001 ) for male youth (20–34 years). This relationship was not substantially modified in males when regression models included prevalences of affective disorders, and other selected mental health variables and demographic factors. From a population perspective, SES remained significantly associated with suicide after controlling for the prevalence of mental disorders and other psychiatric symptomatology. Mental conditions and previous suicidal behaviour may play an intermediary role between SES and suicide, but this study suggests that an independent relationship between suicide and SES also exists.

Suicide in custody

Few risk factors and indicators of vulnerability for suicide in custody are known so far. A case-control study was conducted to investigate the relevance of criminal history, psychiatric morbidity and social integration to suicide in prison. For every suicide that occurred in an Austrian correctional institution between 1975 and 1999, two controls matched for correctional institution, gender, nationality, age, custodial status and time of admission were selected. Psychiatric characteristics, previous suicidal behaviour, criminal history and indicators of social integration were compared. Of 250 recorded suicides, 220 personal files were available and matched to 440 controls. The most important predictors for suicide in custody were a history of suicidality (status following attempted suicide and suicide threat), psychiatric diagnosis, psychotropic medication, a highly violent index offence and single- cell accommodation. A significant finding is the importance of suicidal behaviour as an indicator of risk of suicide in correctional institutions, which until now has been a matter of debate. This study demonstrates the need for staff to take suicidal behaviour as seriously in custodial settings as in any other circumstances.

Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder.

The authors investigated the predictive potential of a stress-diathesis model for suicidal behavior based on correlates of past suicidal acts. In this model, suicidal acts are precipitated by stressors such as life events or a major depressive episode in the setting of a propensity for acting on suicidal urges. This diathesis is expressed as the tendency to develop more pessimism in response to a stressor and/or the presence of aggressive/impulsive traits. The predictive potential of the diathesis was tested by determining whether clinical correlates of past suicidal behavior predict suicidal acts during a 2-year follow-up of patients with a major depressive episode. Patients with DSM-III-R major depressive disorder or bipolar disorder (N=308) were assessed at presentation for treatment of a major depressive episode. Potential predictors of suicidal acts in the 2 years after study enrollment were identified on the basis of an association with previous suicidal behavior and were tested by using Cox proportional hazards regression analysis. In addition, pessimism and aggression/impulsivity factors were generated, and their predictive ability was tested by using Cox proportional hazards regression analysis. The three most powerful predictors of future suicidal acts were a history of suicide attempt, subjective rating of the severity of depression, and cigarette smoking, each of which had an additive effect on future risk. The pessimism and aggression/impulsivity factors both predicted suicidal acts, and each factor showed an additive effect. In addition to obtaining a history of suicidal behavior, clinicians may find it useful to assess patients' current level of pessimism, aggressive/impulsive traits, and comorbidity with substance use disorders, including nicotine-related disorders, to help identify patients at risk for suicidal behavior after major depression. Interventions such as aggressive pharmacotherapeutic prophylaxis to prevent relapse or recurrence of depressive symptoms may protect such at-risk individuals from future suicidal behavior.

Depression and Suicide

Depression and Suicide

Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy

Studies of causes of death among people with epilepsy suggest that the lifetime prevalence rate of suicide is elevated. Although not all of the studies have reported an increased risk for suicide, the collective data yield an average rate of approximately 12% among people with epilepsy, compared with 1.1–1.2% in the general population. The increased risk for suicide appears to affect children and adolescents as well as adults. Rates of suicide attempts have also been reported to be elevated among people with epilepsy. A suicide attempt is a significant risk factor for completed suicide. Certain psychiatric disorders, including primary mood disorders, also increase the risk for suicide. Among people with epilepsy, psychiatric comorbidity is common, and rates of mood disorders, particularly major depression, have consistently been reported to be elevated. Other potential risk factors are family issues, physical health, personality, life stress, previous suicidal behavior, and access to firearms. Assessing severity of risk helps to determine the appropriate level of intervention. The suicidality module of the Mini-International Neuropsychiatric Interview is a practical tool to help quantify current suicide risk.