Suicide

Suicide is a tragic and potentially preventable public health problem. In 2000, suicide was the 11th leading cause of death in the U.S. Specifically, 10.6 out of every 100,000 persons died by suicide. The total number of suicides was 29,350, or 1.2 percent of all deaths. Suicide deaths outnumber homicide deaths by five to three. It has been estimated that there may be from eight to 25 attempted suicides per every one suicide death. The alarming numbers of suicide deaths and attempts emphasize the need for carefully designed prevention efforts.

Suicidal behavior is complex. Some risk factors vary with age, gender and ethnic group and may even change over time. The risk factors for suicide frequently occur in combination. Research has shown that more than 90 percent of people who kill themselves have depression or another diagnosable mental or substance abuse disorder, often in combination with other mental disorders. Also, research indicates that alterations in neurotransmitters such as serotonin are associated with the risk for suicide. Diminished levels of this brain chemical have been found in patients with depression, impulsive disorders, a history of violent suicide attempts, and also in postmortem brains of suicide victims.

Adverse life events in combination with other risk factors such as depression may lead to suicide. However, suicide and suicidal behavior are not normal responses to stress. Many people have one or more risk factors and are not suicidal. Other risk factors include: prior suicide attempt; family history of mental disorder or substance abuse; family history of suicide; family violence, including physical or sexual abuse; firearms in the home; incarceration; and exposure to the suicidal behavior of others, including family members, peers, or even in the media.

Gender Differences

Suicide was the 8th leading cause of death for males and the 19th leading cause of death for females in 2000.1 More than four times as many men as women die by suicide,1 although women report attempting suicide during their lifetime about three times as often as men.5 Suicide by firearm is the most common method for both men and women, accounting for 57 percent of all suicides in 2000. White men accounted for 73 percent of all suicides and 80 percent of all firearm suicides.

Children, Adolescents, and Young Adults

In 2000, suicide was the 3rd leading cause of death among 15- to 24-year-olds -- 10.4 of every 100,000 persons in this age group -- following unintentional injuries and homicide. Suicide was also the 3rd leading cause of death among children ages 10 to 14, with a rate of 1.5 per 100,000 children in this age group. The suicide rate for adolescents ages 15 to 19 was 8.2 deaths per 100,000 teenagers, including five times as many males as females. Among people 20 to 24 years of age, the suicide rate was 12.8 per 100,000 young adults, with seven times as many deaths among men as among women.

Older Adults

Older adults are disproportionately likely to die by suicide. Comprising only 13 percent of the U.S. population, individuals age 65 and older accounted for 18 percent of all suicide deaths in 2000. Among the highest rates (when categorized by gender and race) were white men age 85 and older: 59 deaths per 100,000 persons, more than five times the national U.S. rate of 10.6 per 100,000.

Attempted Suicides

Overall, there may be between eight and 25 attempted suicides for every suicide death; the ratio is higher in women and youth and lower in men and the elderly.2 Risk factors for attempted suicide in adults include depression, alcohol abuse, cocaine use, and separation or divorce.7,8 Risk factors for attempted suicide in youth include depression, alcohol or other drug use disorder, physical or sexual abuse, and disruptive behavior.8,9 As with people who die by suicide, many people who make serious suicide attempts have co-occurring mental or substance abuse disorders. The majority of suicide attempts are expressions of extreme distress and not just harmless bids for attention. A suicidal person should not be left alone and needs immediate mental health treatment.

Prevention

Preventive efforts to reduce suicide should be based on research that shows which risk and protective factors can be modified, as well as which groups of people are appropriate for the intervention. In addition, prevention programs must be carefully tested to determine if they are safe, truly effective, and worth the considerable cost and effort needed to implement and sustain them.

Many interventions designed to reduce suicidality also include the treatment of mental and substance abuse disorders. Because older adults, as well as women who die by suicide, are likely to have seen a primary care provider in the year prior to their suicide, improving the recognition and treatment of mental disorders and other suicide risk factors in primary care settings may be one avenue to prevent suicides among these groups.11 Improving outreach to men at risk for suicide is a major challenge in need of investigation.

Recently, the manufacturer of the medication clozapine received the first ever Food and Drug Administration indication for effectiveness in preventing suicide attempts among persons with schizophrenia.12 Additional promising pharmacologic and psychosocial treatments for suicidal individuals are currently being tested.

If someone is suicidal, he or she must not be left alone. Try to get the person to seek help immediately from his or her doctor or the nearest hospital emergency room, or call 911. It is also important to limit the person's access to firearms, medications, or other lethal methods for suicide.

Common Questions and Answers about Suicide

If someone tells you they are thinking about suicide, you should take their distress seriously, listen nonjudgmentally, and help them get to a professional for evaluation and treatment. People consider suicide when they are hopeless and unable to see alternative solutions to problems. Suicidal behavior is most often related to a mental disorder (depression) or to alcohol or other substance abuse. Suicidal behavior is also more likely to occur when people experience stressful events (major losses, incarceration). If someone is in imminent danger of harming himself or herself, do not leave the person alone. You may need to take emergency steps to get help, such as calling 911. When someone is in a suicidal crisis, it is important to limit access to firearms or other lethal means of committing suicide.

Firearms are the most commonly used method of suicide for men and women, accounting for 60 percent of all suicides. Nearly 80 percent of all firearm suicides are committed by white males. The second most common method for men is hanging; for women, the second most common method is self-poisoning including drug overdose. The presence of a firearm in the home has been found to be an independent, additional risk factor for suicide. Thus, when a family member or health care provider is faced with an individual at risk for suicide, they should make sure that firearms are removed from the home.

More than four times as many men as women die by suicide; but women attempt suicide more often during their lives than do men, and women report higher rates of depression.

There is a common perception that suicide rates are highest among the young. However, it is the elderly, particularly older white males that have the highest rates. And among white males 65 and older, risk goes up with age. White men 85 and older have a suicide rate that is six times that of the overall national rate. Some older persons are less likely to survive attempts because they are less likely to recuperate. Over 70 percent of older suicide victims have been to their primary care physician within the month of their death, many did not tell their doctors they were depressed nor did the doctor detect it. This has led to research efforts to determine how to best improve physicians' abilities to detect and treat depression in older adults.

Impulsiveness is the tendency to act without thinking through a plan or its consequences. It is a symptom of a number of mental disorders, and therefore, it has been linked to suicidal behavior usually through its association with mental disorders and/or substance abuse. The mental disorders with impulsiveness most linked to suicide include borderline personality disorder among young females, conduct disorder among young males and antisocial behavior in adult males, and alcohol and substance abuse among young and middle-aged males. Impulsiveness appears to have a lesser role in older adult suicides. Attention deficit hyperactivity disorder that has impulsiveness as a characteristic is not a strong risk factor for suicide by itself. Impulsiveness has been linked with aggressive and violent behaviors including homicide and suicide. However, impulsiveness without aggression or violence present has also been found to contribute to risk for suicide.

Some right-to-die advocacy groups promote the idea that suicide, including assisted suicide, can be a rational decision. Others have argued that suicide is never a rational decision and that it is the result of depression, anxiety and fear of being dependent or a burden. Surveys of terminally ill persons indicate that very few consider taking their own life, and when they do, it is in the context of depression. Attitude surveys suggest that assisted suicide is more acceptable by the public and health providers for the old who are ill or disabled, compared to the young who are ill or disabled. At this time, there is limited research on the frequency with which persons with terminal illness have depression and suicidal ideation, whether they would consider assisted suicide, the characteristics of such persons, and the context of their depression and suicidal thoughts, such as family stress, or availability of palliative care. Neither is it yet clear what effect other factors such as the availability of social support, access to care, and pain relief may have on end-of-life preferences. This public debate will be better informed after such research is conducted.

Researchers believe that both depression and suicidal behavior can be linked to decreased serotonin in the brain. Low levels of a serotonin metabolite, 5-HIAA, have been detected in cerebral spinal fluid in persons who have attempted suicide, as well as by postmortem studies examining certain brain regions of suicide victims. One of the goals of understanding the biology of suicidal behavior is to improve treatments. Scientists have learned that serotonin receptors in the brain increase their activity in persons with major depression and suicidality, which explains why medications that desensitize or down-regulate these receptors (such as the serotonin reuptake inhibitors, or SSRIs) have been found effective in treating depression. Currently, studies are underway to examine to what extent medications like SSRIs can reduce suicidal behavior.

There is growing evidence that familial and genetic factors contribute to the risk for suicidal behavior. Major psychiatric illnesses, including bipolar disorder, major depression, schizophrenia, alcoholism and substance abuse, and certain personality disorders, which run in families, increase the risk for suicidal behavior. This does not mean that suicidal behavior is inevitable for individuals with this family history; it simply means that such persons may be more vulnerable and should take steps to reduce their risk, such as getting evaluation and treatment at the first sign of mental illness.

Although the majority of people who have depression do not die by suicide, having major depression does increase suicide risk compared to people without depression. The risk of death by suicide may, in part, be related to the severity of the depression. New data on depression that has followed people over long periods of time suggests that about 2% of those people ever treated for depression in an outpatient setting will die by suicide. Among those ever treated for depression in an inpatient hospital setting, the rate of death by suicide is twice as high (4%). Those treated for depression as inpatients following suicide ideation or suicide attempts are about three times as likely to die by suicide (6%) as those who were only treated as outpatients. There are also dramatic gender differences in lifetime risk of suicide in depression. Whereas about 7% of men with a lifetime history of depression will die by suicide, only 1% of women with a lifetime history of depression will die by suicide.

Another way of thinking about suicide risk and depression is to examine the lives of people who have died by suicide and see what proportion of them were depressed. From that perspective, it is estimated that about 60% of people who commit suicide have had a mood disorder (e.g., major depression, bipolar disorder, dysthymia). Younger persons who kill themselves often have a substance abuse disorder in addition to being depressed.

A number of recent national surveys have helped shed light on the relationship between alcohol and other drug use and suicidal behavior. A review of minimum-age drinking laws and suicides among youths age 18 to 20 found that lower minimum-age drinking laws were associated with higher youth suicide rates. In a large study following adults who drink alcohol, suicide ideation was reported among persons with depression. In another survey, persons who reported that they had made a suicide attempt during their lifetime were more likely to have had a depressive disorder, and many also had an alcohol and/or substance abuse disorder. In a study of all nontraffic injury deaths associated with alcohol intoxication, over 20 percent were suicides.

In studies that examine risk factors among people who have committed suicide, substance use and abuse occurs more frequently among youth and adults, compared to older persons. For particular groups at risk, depression and alcohol use and abuse are the most common risk factors for suicide. Alcohol and substance abuse problems contribute to suicidal behavior in several ways. Persons who are dependent on substances often have a number of other risk factors for suicide. In addition to being depressed, they are also likely to have social and financial problems. Substance use and abuse can be common among persons prone to be impulsive, and among persons who engage in many types of high risk behaviors that result in self-harm. Fortunately, there are a number of effective prevention efforts that reduce risk for substance abuse in youth, and there are effective treatments for alcohol and substance use problems. Researchers are currently testing treatments specifically for persons with substance abuse problems who are also suicidal, or have attempted suicide in the past.

Suicide contagion is the exposure to suicide or suicidal behaviors within one's family, one's peer group, or through media reports of suicide and can result in an increase in suicide and suicidal behaviors. Direct and indirect exposure to suicidal behavior has been shown to precede an increase in suicidal behavior in persons at risk for suicide, especially in adolescents and young adults.

The risk for suicide contagion as a result of media reporting can be minimized by factual and concise media reports of suicide. Reports of suicide should not be repetitive, as prolonged exposure can increase the likelihood of suicide contagion. Suicide is the result of many complex factors; therefore media coverage should not report oversimplified explanations such as recent negative life events or acute stressors. Reports should not divulge detailed descriptions of the method used to avoid possible duplication. Reports should not glorify the victim and should not imply that suicide was effective in achieving a personal goal such as gaining media attention. In addition, information such as hotlines or emergency contacts should be provided for those at risk for suicide.

Following exposure to suicide or suicidal behaviors within one's family or peer group, suicide risk can be minimized by having family members, friends, peers, and colleagues of the victim evaluated by a mental health professional. Persons deemed at risk for suicide should then be referred for additional mental health services.

At the current time there is no definitive measure to predict suicide or suicidal behavior. Researchers have identified factors that place individuals at higher risk for suicide, but very few persons with these risk factors will actually commit suicide. Risk factors include mental illness, substance abuse, previous suicide attempts, family history of suicide, history of being sexually abused, and impulsive or aggressive tendencies. Suicide is a relatively rare event and it is therefore difficult to predict which persons with these risk factors will ultimately commit suicide.