Suicide
Suicide
Treatment of attempted suicide
Definition
Suicide is defined as the intentional taking of one’s own life. In some European languages, the word for suicide translates into English as “self-murder.” Until the end of the twentieth century, approximately, suicide was considered a criminal act; legal terminology used the Latin phrase felo-de-se, which means “a crime against the self.” Much of the social stigma that is still associated with suicide derives from its former connection with legal judgment, as well as with religious condemnation.
In the social climate of 2007, suicidal behavior is most commonly regarded—and responded to—as a psychiatric emergency.
Demographics of suicide
There are almost 11 suicide deaths each year for every 100,000 people living the United States, and for every suicide, there were between eight and 20 attempts. There are over 30,000 suicides each year in the United States, or about 82 each day; each day about 1,500 people attempt suicide. The demographics of suicide vary considerably from state to state, with rates higher than the national average in the West and lower in the Midwest and Northeast. Some states, like Alaska, have suicide rates that are almost twice the national average; others, such as Massachusetts, have notably lower rates.
These variations from state to state result in part from differences in age and ethnic distributions and gender ratios among the states. In 2004, suicide was the eleventh leading cause of death in the United States, according to the National Institute of Mental Health, and it was the eighth leading cause of death among males and sixteenth leading cause of death among females. Males are four times more likely
than females to succeed in their suicide attempts, but females report attempting suicide sometime in their lives three times as often as men. Among ethnic groups, suicide rates are highest among white males, followed closely by American Indian and Native Alaskan males. In terms of age, most suicides are committed by people under age 40, but suicide rates (percentages in a given group) increase with age. People over age 65 have high suicide rates, with men outnumbering women who commit suicide nearly four to one. Among people over age 65, suicide rates are high compared to the national average, with slightly more than 14 deaths for every 100,000 people in this age group, and among Hispanic men in this age group, rates are even higher at almost 18 deaths per 100,000 men.
The overall rate of suicide among young people has declined slowly since 1992, but it still remains the third leading cause of death in age groups spanning children 10 years old to young adults up to age 24. Suicides among young people ages 15 to 24 show an extreme male bias: Four times as many males as females ages 15 to 19 and six times as many males age 20 to 24 committed suicide in 2004. Over half of suicides in this group were firearm related, and males in general are far more likely to use firearms.
High-risk factors
Research indicates that the following factors increase a person’s risk of suicide:
- Male sex.
- Age over 75.
- A family history of suicide.
- A history of suicide attempts.
- A history of abuse in childhood.
- Traumatic experiences after childhood
- Recent stressful events, such as separation or divorce, job loss, or death of spouse.
- Chronic medical illness. Patients with AIDS have a rate of suicide 20 times that of the general population.
- Access to a firearm. Death by firearms now accounts for the majority of suicides.
- Alcohol or substance abuse. While mood-altering substances do not cause a person to kill himself or herself, they weaken impulse control.
- High blood cholesterol levels.
- Presence of a psychiatric illness. Over 90% of Americans who commit suicide have a mental illness. Major depression accounts for 60% of suicides, followed by schizophrenia, alcoholism, substance abuse, borderline personality disorder, Huntington’s disease, and epilepsy. The lifetime mortality due to suicide in psychiatric patients is 15% for major depression; 20% for bipolar disorder; 18% for alcoholism; 10% for schizophrenia; and 5-10% for borderline and certain other personality disorders.
Low-risk factors
Factors that lower a person’s risk of suicide include:
- A significant friendship network outside the workplace.
- Religious faith and practice, especially those that discourage suicide and encourage self preservation.
- A stable marriage.
- A close-knit extended family.
- A strong interest in or commitment to a project or cause that brings people together: community service, environmental concerns, neighborhood associations, animal rescue groups, etc.
Suicide in other countries
Suicide has become a major social and medical problem around the world. The World Health Organization (WHO) reported that one million people worldwide died from suicide in the year 2000. That is a global mortality rate of 16:100,000—or one death by suicide every 40 seconds. Since the mid-1950s, suicide rates around the world have risen by 60%. Rates among young people have risen even faster, to the point where they are now the age group at highest risk in 35% of the world’s countries.
The specific demographics, however, vary from country to country. China’s pattern, for example, is very different from that of most other countries. China has a suicide mortality rate of 23:100,000, with a total of 287,000 deaths by suicide each year. The rate for women is 25% higher than that for men, and rates in rural areas are three times higher than in cities. The means also vary; in China, Sri Lanka, and Turkey the primary means of suicide is ingestion of pesticides, rather than using firearms.
Causes
Suicide is an act that represents the end result of a combination of factors in any individual. One model that has been used by clinicians to explain why people suffering under the same life stresses respond differently is known as the stress/diathesis model. Diathesis is a medical term for a predisposition that makes some people more vulnerable to thoughts of suicide. In addition to factors at the individual level, factors in the wider society have been identified as contributing to the rising rate of suicide in the United States:
- Stresses on the nuclear family, including divorce and economic hardship.
- The loss of a set of moral values held in common by the entire society.
- The weakening of churches, synagogues, and other mid-range social groups outside the family. In the past, these institutions often provided a sense of belonging for people from troubled or emotionally distant families.
- Frequent geographical moves, which makes it hard for people to make and keep long-term friendships outside their immediate family.
- Sensationalized treatment of suicide in the mass media. A number of research studies have shown that there is a definite risk of “contagion” suicides from irresponsible reporting, particularly among impressionable adolescents.
- The development over the past century of medications that allow relatively painless suicide. For most of human history, the available means of suicide were uncertain, painful, or both.
- The easy availability of firearms in the United States.
Treatment of attempted suicide
Researchers estimate that 8-25 people attempt suicide for every person who completes the act. Suicide attempts can be broadly categorized along a continuum that ranges from seriously planned attempts involving a highly lethal method that fail by chance to impulsive or poorly planned attempts using a less lethal method. Suicide attempts at the lower end of the spectrum are sometimes referred to as suicide gestures or pseudocide.
A suicide attempt of any kind, however, is treated as a psychiatric emergency by rescue personnel. Treatment in a hospital emergency room includes a complete psychiatric evaluation, a mental status examination, and a detailed assessment of the circumstances surrounding the attempt. The physician will interview relatives or anyone else who accompanied the patient in order to obtain as much information as possible. As a rule, suicide attempts requiring advance planning, including precautions taken against discovery, and the use of violent or highly lethal methods are regarded as the most serious. The patient will be kept under observation while decisions are made about the need for hospitalization.
A person who has attempted suicide and who is considered a serious danger to him- or herself or to others can be hospitalized against their will. The doctor will base the decision on the severity of the patient’s depression or agitation; availability of friends, relatives, or other social support; and the presence of other suicide risk factors, including a history of previous suicide attempts, substance abuse, recent stressful events, and symptoms of psychosis. If the attempt is judged to be a nonlethal suicide gesture, the patient may be released after the psychiatric assessment is completed.
Related issues
Survivors of suicide
One group of people that is often overlooked in discussions of suicide is the friends and family of the victim. It is estimated that each person who kills himself or herself leaves six survivors to deal with the aftermath. Based on this figure, there are some 4.5 million survivors of suicide in the United States. In addition to the grief that ordinarily accompanies death, survivors of suicide often struggle with feelings of guilt and shame as well. In spite of a general liberalization of social attitudes since World War II, suicide is still stigmatized in many parts of Europe and the United States. Survivors often benefit from group or individual psychotherapy in order to work through such issues as wondering whether they could have prevented the suicide or whether they are likely to commit suicide themselves. Increasing numbers of clergy as well as mental health professionals are taking advanced training in counseling survivors of suicide.
Assisted suicide
One question that has been raised in developed countries as the average life expectancy increases is the legalization of assisted suicide a person suffering from a painful terminal illness. Physician-assisted suicide and euthanasia have become topics of concern since legalization of one or both by recent legislation in the Netherlands (in April 2001), Belgium (in 2002), and in the state of Oregon (passed in 1994; upheld by the U.S. Supreme Court in 2005). It is important to distinguish between physician-assisted suicide and euthanasia, or “mercy killing.” Assisted suicide, which is often called “self-deliverance” in Britain, refers to a person’s bringing about his or her own death with the help of another person. Because the other person is often a doctor, the act is often called “physician-assisted suicide.” Strictly speaking, euthanasia means that the physician or other person is the one who performs the last act that causes death. For example, if a physician injects a patient with a lethal overdose of a medication, he or she is performing euthanasia. If the physician leaves the patient with a loaded syringe and the patient injects himself or herself with it, the act is an assisted suicide. As of 2007, assisted suicide is illegal everywhere in the
KEY TERMS
Assisted suicide —A form of self-inflicted death in which a person voluntarily brings about his or her own death with the help of another, usually a physician, relative, or friend.
Cortisol —A steroid hormone released by the cortex (outer portion) of the adrenal gland when a person is under stress. Cortisol levels are now considered a biological marker of suicide risk.
Dexamethasone test —Serves as a marker of suicide risk by reflecting signaling activity between the brain and the adrenal gland.
Diathesis —The medical term for predisposition. The stress/diathesis model is a diagram that is used to explain why some people are at greater risk of suicidal behavior than others.
Euthanasia —The act of putting a person or animal to death painlessly or allowing them to die by withholding medical services, usually because of a painful and incurable disease. Mercy killing is another term for euthanasia.
Frontal cortex —The part of the human brain associated with aggressiveness and impulse control. Abnormalities in the frontal cortex are associated with an increased risk of suicide.
Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle, and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.
Slow suicide —A term used to refer to lifestyle behaviors known to shorten life expectancy, such as smoking, drinking heavily, having unsafe sex, etc.
Suicide gesture —Attempted suicide characterized by a low-lethality method, low level of intent or planning, and little physical damage. Pseudocide is another term for a suicide gesture.
United States except for Oregon, and euthanasia is illegal in all fifty states.
Media treatment of suicide
In 1989, the Centers for Disease Control (CDC) sponsored a national workshop to address the issue of the connection between sensationalized media treatments of suicide and the rising rate of suicide among American youth. The CDC and the American Association of Suicidology subsequently adopted a set of guidelines for media coverage of suicide intended to reduce the risk of suicide by contagion.
The CDC guidelines point out that the following types of reporting may increase the risk of “copycat” suicides:
- Presenting oversimplified explanations of suicide, when in fact many factors usually contribute to it. One example concerns the suicide of the widow of a man who was killed in the collapse of the World Trade Center on September 11, 2001. Most newspapers that covered the story described her death as due solely to the act of terrorism, even though she had a history of depressive illness.
- Excessive, ongoing, or repetitive coverage of the suicide.
- Sensationalizing the suicide by inclusion of morbid details or dramatic photographs. Some news accounts of the suicide of an Enron executive in January 2002 are examples of this problem.
- Giving “how-to” descriptions of the method of suicide.
- Referring to suicide as an effective coping strategy or as a way to achieve certain goals.
- Glorifying the act of suicide or the person who commits suicide.
- Focusing on the person’s positive traits without mentioning his or her problems.
Prevention
Research on brain physiology has become an important aspect of suicide prevention. Because major depression is the single most common diagnosis in suicidal people, earlier and more effective recognition of depression is a necessary preventive measure. Known biological markers for an increased risk of suicide can now be correlated with personality profiles linked to suicidal behavior under stress to help identify individuals at risk. One new clinical parameter that may be considered with personality profiles is the dexamethasone suppression test, which serves as an indicator of hyperactivity of a neuroendocrine hormonal pathway between the brain and the adrenal gland. Another clinical parameter that may be combined with psychological assessment is an assessment of
serotonin function based on cholesterol levels, with high levels indicating a risk. In addition, brain imaging studies using positron emission tomography (PET) are being used to detect abnormal patterns of serotonin uptake in specific regions of the brain. Genetic studies are also yielding new information about inherited predispositions to suicide.
A second major preventive measure is education of clinicians, media people, and the general public. Public health studies carried out in Sweden have shown that seminars for primary care physicians in the recognition and treatment of depression resulted in a rise in the number of prescriptions for antidepressants and a drop in suicide rates. Education of the general public includes a growing number of CDC, NIMH, and other web sites posting information about suicide, tips for identifying symptoms of depressed and suicidal thinking, and advice about helping friends or loved ones who may be at risk. Many of these web sites have direct connections to suicide hotlines.
An additional preventive strategy is restricting access to firearms in the developed countries and to pesticides and other poisons in countries where these are the preferred method of suicide.
Resources
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington D.C.: American Psychiatric Association, 2000.
Eisendrath, Stuart J., MD, and Jonathan E. Lichtmacher, MD. “Psychiatric Disorders.” Current Medical Diagnosis & Treatment 2001. Ed. L. M. Tierney Jr., MD, and others. 40th ed. New York: Lange Medical Books/McGraw-Hill, 2001.
“Psychiatric Emergencies.” Section 15, Chapter 194. The Merck Manual of Diagnosis and Therapy. Ed. Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.
“Suicidal Behavior.” Section 15, Chapter 190. The Merck Manual of Diagnosis and Therapy. Ed. Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.
“Suicide in Children and Adolescents.” Section 19, Chapter 264. The Merck Manual of Diagnosis and Therapy. Ed. Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
PERIODICALS
Coryell, William H., MD. “Clinical assessment of suicide risk in depressive disorder.” CNS Spectrums 11(2006): 255–461.
Fu, Q., A. C. Heath, K. K. Bucholz, and others. “A Twin Study of Genetic and Environmental Influences on Suicidality in Men.” Psychology in Medicine 32 (January 2002): 11–24.
Gibb, Brandon E., Lauren B. Alloy, Lyn Y. Abramson, and others. “Childhood Maltreatment and College Students’ Current Suicidal Ideation: A Test of the Hopelessness Theory.” Suicide and Life-Threatening Behavior 31 (2001): 405–15.
Mancinelli, Iginia, MD, and others. “Mass Suicide: Historical and Psychodynamic Considerations.” Suicide and Life-Threatening Behavior 32 (2002): 91–100.
ORGANIZATIONS
American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. www.aacap.org
American Association of Suicidology. Suite 310, 4201 Connecticut Avenue, NW, Washington, DC 20008. (202) 237-2280. Fax: (202) 237-2282. www.suicidology.org
National Institutes of Mental Health (NIMH). NIMH Public Inquiries: (800) 421-4211. www.nimh.nih.gov
WEB SITES
World Health Organization. “Suicide: Fact Sheet” http://www.cdc.gov/ncipc/factsheets/suifacts.htm and http://www.cdc.gov/nchs/fastats/suicide.htm
National Institute of Mental Health. NIH publication 03-4594 (2006) “Suicide in the U.S.: statistics and prevention.” http://www.nimh.nih.gov/publicat/harmaway.cfm
Suicide Prevention Resource Center. State-by-state information. http://www.sprc.org/stateinformation and http://www.sprc.org/stateinformation/datasheets.asp
National Library of Medicine. “Suicide” http://www.nlm.nih.gov/medlineplus/suicide.html
World Health Organization. “Suicide prevention” http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/
OTHER
Befrienders International. www.befrienders.org
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Programs for the Prevention of Suicide Among Adolescents and Young Adults; and Suicide Contagion and the Reporting of Suicide: Recommendations from a National Workshop. MMWR 1994; 43 (No. RR-6). www.cdc.gov/ncipc
Mann, J. John, MD. “The Neurobiology of Suicide.” Mental Health Clinical Research Center for the Study of Suicidal Behavior, Columbia-Presbyterian Medical Center, New York. www.afsp.org
National Suicide Hotline: (800) SUICIDE (800-784-2433).
Rebecca Frey, Ph.D.
Emily Jane Willingham, Ph.D.