Suicide



Suicide 981
Photo by: Jirsak

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 2002, suicidal behavior is most commonly regarded— and responded to— as a psychiatric emergency.

Demographics of suicide

In the United States, the rate of suicide has continued to rise since the 1950s. More people die from suicide than from homicide in North America. Suicide is the eighth leading cause of death in the U.S., and the third leading cause of death for people aged 15 to 24. There are over 30,000 suicides per year in the U.S., or about 86 per day; each day about 1,500 people attempt suicide.

The demographics of suicide vary considerably from state to state. Some states, like Pennsylvania, have suicide rates that are very close to the national average; others, such as Connecticut, have significantly lower rates. However, other states have much higher rates than the national average. These variations are due in part to differences among age groups and racial groups, and between men and women. Males are three to five times more likely to succeed in their suicide attempts than females, but females are more likely to attempt suicide. Most suicides occur in persons below the age of 40; however, elderly Caucasians are the sector of the population with the highest suicide rate.

Race is also a factor in the demographics of suicide. Between 1979 and 1992, the suicide rate of Native Americans was 1.5 times the national average, with young males between the ages of 15 and 24 accounted for 64% of Native American deaths by suicide. Asian-American women have the highest suicide rate among all women over the age of 65. Further, between 1980 and 1996 the suicide rate more than doubled for African-American males between the ages of 15 and 19.

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 gun. Death by firearms is now the fastestgrowing method of suicide among men and women. Nearly 57% of deaths caused by guns in the U.S. are suicides.
  • Alcohol or substance abuse. While mood-altering substances do not cause a person to kill himself/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
  • a stable marriage
  • a close-knit extended family
  • a strong interest in or commitment to a project or cause that brings people together, including 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 guns.

Suicide in children and adolescents

The suicide rate among children and adolescents in the U.S. has risen faster than that of the world population as a whole. The suicide rate for Caucasian males aged 15 to 24 years has tripled since 1950; and it has more than doubled for Caucasian females in the same age bracket. In 1999, a survey of high school students found that 20% had seriously considered suicide or attempted it in the previous year. Of adolescents who do commit suicide, 90% have at least one diagnosable psychiatric disorder at the time of their death. Most frequently it is major depression, substance abuse disorder, or conduct disorder . Adolescents are particularly susceptible to dramatic or glamorized portrayals of suicide in the mass media.

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. Components of a person's diathesis may include:

Neurobiological and genetic factors

Post-mortem studies of the brains of suicide victims indicate that the part of the brain associated with controlling agression and other impulsive behaviors (the frontal cortex) has a significantly lower level of serotonin, a neurotransmitter associated with mood disorders. Low serotonin levels are correlated with major depression. In addition, suicide victims have higher than normal levels of cortisol, a hormone produced in stressful situations, in the tissues of their central nervous system. Studies of the levels of other neurotransmitters in brain tissue are underway.

Other research has indicated that abuse in childhood may have permanent effects on the level of serotonin in the brain, possibly "resetting" the level abnormally low. In addition, twin studies have suggested that there may be genetic susceptibility in males to both suicidal ideation and suicide attempts which cannot be explained by inheritance of common psychiatric disorders. No twin studies of susceptibility to suicide in women have yet been reported.

History and lifestyle

Other components of a diathesis include:

  • Chronic illness
  • Traumatic experiences after childhood
  • Alcohol or substance abuse
  • High blood cholesterol levels.

Factors in the wider society

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 good fortune, 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 bereaved by the suicide. It is estimated that each person who kills him- or herself leaves six survivors to deal with the aftermath. On the basis of this figure, there are at least 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 for persons suffering from a painful terminal illness. Physician-assisted suicide has become a topic of concern since it was legalized by recent legislation in the Netherlands (in April 2001) and in the state of Oregon. 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 physician, the act is often called "doctor-assisted suicide." Euthanasia strictly speaking 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 pain-killing 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 2002, assisted suicide is illegal every where in the 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

Brain research is an important aspect of suicide prevention as of 2002. Since 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. In addition, brain imaging studies using positron emission tomography (PET) are presently in use 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 edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Eisendrath, Stuart J., MD, and Jonathan E. Lichtmacher, MD. "Psychiatric Disorders." In Current Medical Diagnosis & Treatment 2001 , edited by L. M. Tierney, Jr., MD, and others. 40th edition. New York: Lange Medical Books/McGraw-Hill, 2001.

"Psychiatric Emergencies." Section 15, Chapter 194 in The Merck Manual of Diagnosis and Therapy , edited by MarkH. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

"Suicidal Behavior." Section 15, Chapter 190 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

"Suicide in Children and Adolescents." Section 19, Chapter 264 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories,1999.

PERIODICALS

Byard, R. W., and J. D. Gilbert. "Cervical Fracture, Decapitation, and Vehicle-Assisted Suicide." Journal of Forensic Science 47 (March 2002): 392-394.

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): 405-415.

Kara, I. H., and others. "Sociodemographic, Clinical, and Laboratory Features of Cases of Organic Phosphorus Intoxication in the Southeast Anatolian Region of Turkey." Environmental Research 88 (February 2002): 82-88.

Mancinelli, Iginia, MD, and others. "Mass Suicide: Historical and Psychodynamic Considerations." Suicide and Life-Threatening Behavior 32 (2002): 91-100.

Phillips, M. R., X Li, and Y. Zhang. "Suicide Rates in China, 1995-99." Lancet 359 (March 9, 2002): 835-840.

Plunkett, A., B. O'Toole, H. Swanston, and others. "Suicide Risk Following Child Sexual Abuse." Ambulatory Pediatrics 1 (September-October 2001): 262-266.

Vieta, E., F. Colom, B. Corbella, and others. "Clinical Correlates of Psychiatric Comorbidity in Bipolar I Patients." Bipolar Disorders 3 (October 2001): 253-258.

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> .

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 J. Frey, Ph.D.



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