Suicide is defined as the intentional taking of one's own life. Prior to the late nineteenth century, suicide was legally defined as a criminal act in most Western countries. In the social climate of the early 2000s, however, suicidal behavior is most commonly regarded and responded to as a psychiatric emergency.
Suicide is considered a major public health problem around the world as well as a personal tragedy. According to the National Institute of Mental Health (NIMH), suicide was the eleventh leading cause of death
in the United States in 2000, and the third leading cause of death for people between the ages of 15 and 24. About 10.6 out of every 100,000 persons in the United States and Canada die by their own hands. There are five suicide victims for every three homicide deaths in North America as of the early 2000s. There are over 30,000 suicides per year in the United States, or about 86 per day; and each day about 1900 people attempt suicide.
The demographics of suicide vary considerably within Canada and the United States, due in part to differences among age groups and racial groups, and between men and women. Adult males are three to five times more likely to commit suicide 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. Americans over the age of 65 accounted for 18 percent of deaths by suicide in the United States in 2000. Geographical location is an additional factor; according to the Centers for Disease Control and Prevention (CDC), suicide rates in the United States are slightly higher than the national average in the western states, and somewhat lower than average in the East and the Midwest.
Race is also a factor in the demographics of suicide. Between 1979 and 1992, Native Americans had a suicide rate 1.5 times the national average, with young males between 15 and 24 accounting for 64% of Native American deaths by suicide. Asian American women have the highest suicide rate among all women over the age of 65. And between 1980 and 1996 the suicide rate more than doubled for black males between the ages of 15 and 19.
Causes & symptoms
Suicide is a complex act that represents the end result of a combination of factors in any individual. These factors include biological vulnerabilities, life history, occupation, present social circumstances, and the availability of means for committing suicide. While these factors do not "cause" suicide in the strict sense, some people are at greater risk of self-harm than others. Risk factors for suicide include:
- Male sex.
- Age over 75.
- A family history of suicide.
- A history of previous suicide attempts.
- A history of abuse in childhood.
- A local cluster of recent suicides or a local landmark associated with suicides. Examples of the latter include the Golden Gate Bridge in San Francisco; Sydney Harbor Bridge in Australia; St. Peter's Basilica in Rome; the Eiffel Tower in Paris; Prince Edward Viaduct in Toronto; and Mount Mihara, a volcano in Japan.
- Recent stressful events: separation or divorce, job loss, bankruptcy, upsetting medical diagnosis, death of spouse.
- Medical illness. Persons in treatment for such serious or incurable diseases as AIDS, Parkinson's disease, and certain types of cancer are at increased risk of suicide.
- Employment as a police officer, firefighter, physician, dentist, or member of another high-stress occupation.
- Presence of firearms in the house. Death by firearms is the most common method for women as well as men as of the early 2000s. In 2001, 55% of reported suicides in the United States were committed with guns.
- Alcohol or substance abuse. Mood-altering substances are a factor in suicide because they weaken a person's impulse control.
- Presence of a psychiatric illness. Over 90% of Americans who commit suicide have a significant mental illness. Major depression accounts for 60% (especially in the elderly), 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.
Neurobiological factors may also influence a person's risk of suicide. Post-mortem studies of the brains of suicide victims indicate that the part of the brain associated with aggression 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. 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 a genetic susceptibility to both suicidal ideation and suicide attempts which cannot be explained by inheritance of common psychiatric disorders.
Some psychiatrists propose psychodynamic explanations of suicide. According to one such theory, suicide is "murder in the 180th degree" that is, the suicidal person really wants to kill someone else but turns the anger against the self instead. Another version of this idea is that the suicidal person has incorporated the image of an abusive parent or other relative in their own psyche and then tries to eliminate the abuser by killing the self.
When a person consults a doctor because they are thinking of committing suicide, or they are taken to a doctor's office or emergency room after a suicide attempt, the doctor will evaluate the patient's potential for acting on their thoughts or making another attempt. The physician's assessment will be based on several different sources of information:
- The patient's history, including a history of previous attempts or a family history of suicide.
- A clinical interview in which the physician will ask whether the patient is presently thinking of suicide; whether they have made actual plans to do so; whether they have thought about the means; and what they think their suicide will accomplish. These questions help in evaluating the seriousness of the patient's intentions.
- A suicide note, if any.
- Information from friends, relatives, or first responders who may have accompanied the patient.
- Short self-administered psychiatric tests that screen people for depression and suicidal ideation. The most commonly used screeners are the Beck Depression Inventory (BDI), the Depression Screening Questionnaire, and the Hamilton Depression Rating Scale.
- The doctor's own instinctive reaction to the patient's mood, appearance, vocal tone, and similar factors.
Treatment of attempted suicide
Suicide attempts range from well-planned attempts involving a highly lethal method (guns, certain types of poison, jumping from high places, throwing oneself in front of trains or subway cars) that fail by good fortune to impulsive or poorly planned attempts using a less lethal method (medication overdoses, cutting the wrists). Suicide attempts at the less lethal end of the spectrum are sometimes referred to as suicide gestures or pseudocide. These terms should not be taken to indicate that suicide gestures are only forms of attention-seeking; they should rather be understood as evidence of serious emotional and mental distress.
A suicide attempt of any kind is treated as a psychiatric emergency by the police and other rescue personnel. Treatment in a hospital emergency room includes a complete psychiatric evaluation; a mental status examination
; blood or urine tests if alcohol or drug abuse is suspected; and a detailed assessment of the patient's personal circumstances (occupation, living situation, family or friends nearby, etc.). The patient will be kept under observation while decisions are made about the need for hospitalization.
A person who has attempted suicide can be legally hospitalized against his or her will if he or she seems to be a danger to the self or others. The doctor will base decisions about hospitalization on the severity of the patient's depression; the 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, and psychosis
(loss of contact with reality, often marked by delusions
). If the attempt is judged to be a nonlethal suicide gesture, the patient may be released after the psychiatric assessment is completed. According to CDC figures, 132,353 Americans were hospitalized in 2002 following suicide attempts while 116,639 were released following emergency room treatment.
Survivors of suicide
One group of people that is often overlooked in discussions of suicide is the friends and family left behind by the suicide. It is estimated that each person who kills him- or herself leaves six survivors to deal with the aftermath; thus 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. They 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. The American Foundation for Suicide Prevention (AFSP) has a number of online resources available for survivors of 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 in the Netherlands in 2001 and in the state of Oregon in 1997. 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 early 2005 assisted suicide is illegal everywhere in the United States except for Oregon, and euthanasia is illegal in all fifty states.
Media treatment of suicide
The Centers for Disease Control and Prevention (CDC) sponsored a national workshop in April 1994 that addressed 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 a person's decision to take their own life.
- Excessive or repetitive local news coverage.
- Sensationalizing the suicide by inclusion of morbid details or dramatic photographs.
- Giving "how-to" descriptions of the method of suicide.
- Describing 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.
Some alternative treatments may help to prevent suicide by preventing or relieving depression. Meditation
practice or religious faith and worship have been shown to lower a person's risk of suicide. In addition, any activity that brings people together in groups and encourages them to form friendships helps to lower the risk of suicide, as people with strong social networks are less likely to give up on life.
The prognosis for a person who has attempted suicide is generally favorable, although further research needs to be done. A 1978 follow-up study of 515 people who had attempted suicide between 1937 and 1971 reported that 94% were either still alive or had died of natural causes. This finding has been taken to indicate that suicidal behavior is more likely to be a passing response to an acute crisis than a reflection of a permanent state of mind.
One reason that suicide is such a tragedy is that most self-inflicted deaths are potentially preventable. Many suicidal people change their minds if they can be helped through their immediate crisis; Dr. Richard Seiden, a specialist in treating survivors of suicide attempts, puts the high-risk period at 90 days after the crisis. Some potential suicides change their minds during the actual attempt; for example, a number of people who survived jumping off the Golden Gate Bridge told interviewers afterward that they regretted their action even as they were falling and that they were grateful they survived.
Brain research is another important aspect of suicide prevention. Since major depression is the single most common psychiatric 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.
Another major preventive measure is education of clinicians, media people, and the general public. In 2002 the CDC, the National Institutes of Health (NIH), and several other government agencies joined together to form the National Strategy for Suicide Prevention, or NSSP. Education of the general public includes a growing number of medical and government websites posting information about suicide, publications available for downloading, lists of books for further reading, 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 websites also have direct connections to suicide hotlines.
The National Institute of Mental Health (NIMH) recommends the following action steps for anyone dealing with a suicidal person:
- Make sure that someone is with them at all times; do not leave them alone even for a short period of time.
- Persuade them to call their family doctor or the nearest hospital emergency room.
- Call 911 yourself.
- Keep the person away from firearms, drugs, or other potential means of 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.
— A 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.
— 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.
— 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.
— A type of explanation of human behavior that regards it as the outcome of interactions between conscious and unconscious factors.
— A chemical that occurs in the blood and nervous tissue and functions to transmit signals across the gaps between neurons in the central nervous system. Abnormally low levels of serotonin are associated with depression and an increased risk of suicide.
— 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.
Alvarez, A. The Savage God: A Study of Suicide. New York: Random House, Inc., 1972. A now-classic study of suicide written for general readers. The author includes a historical overview of suicide along with accounts of his own suicide attempt and the suicide of his friend, the poet Sylvia Plath.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.
"Depression." In The Merck Manual of Geriatrics, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
"Psychiatric Emergencies." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
"Suicidal Behavior." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
"Suicide in Children and Adolescents." In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
Friend, Tad "Letter from California: Jumpers." New Yorker, 10 November 2003. 〈http://newyorker.com/printable/?fact/031013fa_fact〉. A journalist's account of the Golden Gate Bridge in San Francisco, the world's leading location for suicide.
Fu, Q., A. C. Heath, K. K. Bucholz, et al. "A Twin Study of Genetic and Environmental Influences on Suicidality in Men." Psychology in Medicine 32 (January 2002): 11-24.
Plunkett, A., B. O'Toole, H. Swanston, et al. "Suicide Risk Following Child Sexual Abuse." Ambulatory Pediatrics 1 (September-October 2001): 262-266.
Soreff, Stephen, MD. "Suicide." eMedicine, 3 September 2004. http://www.emedicine.com/med/topic3004.htm.
American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. http://www.aacap.org..
American Association of Suicidology. Suite 408, 4201 Connecticut Avenue, NW, Washington, DC 20008. (202) 237-2280. Fax: (202) 237-2282. http://www.suicidology.org.
American Foundation for Suicide Prevention (AFSP). 120 Wall Street, 22nd Floor, New York, NY 10005. (888) 333-2377 or (212)
Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC). Mailstop K60, 4770 Buford Highway, Atlanta, GA 30341-3724. (770) 488-4362. Fax: (770) 488-4349. 〈http://www.cdc.gov/ncipc.htm〉.
National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (886) 615-NIMH. www.nimh.nih.gov.
American Academy of Child and Adolescent Psychiatry (AACAP). Teen Suicide. AACAP Facts for Families #10. Washington, DC: AACAP, 2004.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. "Suicide Contagion and the Reporting of Suicide: Recommendations from a National Workshop." Morbidity and Mortality Weekly Report 43 (22 April 1994): 9-18. http://www.cdc.gov/mmwr/preview/mmwrhtml/00031539.htm.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Suicide: Fact Sheet. http://www.cdc.gov/ncipc/factsheets/suifacts.htm.
National Institute of Mental Health (NIMH). In Harm's Way: Suicide in America. NIH Publication No. 03-4594. Bethesda, MD: NIMH, 2003. http://www.nimh.nih.gov/publicat/NIMHharmsway.pdf.
National Suicide Hotline: (800) 273-TALK (1-800-273-8255).