Suicide

George Nitzburg . Elizabeth Midlarsky

Suicide, defined as the purposeful ending act of one’s life, can be characterized as a spectrum that ranges from suicidal ideation, through suicide attempts or gestures, to suicidal behavior.

Suicidal ideation includes the spectrum from fleeting suicidal thoughts to a well-organized plan, including the choice of a lethal weapon. Almost a third of all people experience suicidal ideation during their lifetimes, but few act on their thoughts. While those thinking about suicide rarely attempt suicide, almost all suicide attempts are preceded by suicidal ideation.

Parasuicide, or suicide attempts refer to deliberate self-harm (such as self-poisoning) which does not, however, result in death. Suicide attempts outnumber completed suicides. For every completed suicide there are 8–25 suicide attempts. Individuals can engage in parasuicide as a ‘‘cry for help,’’ by choosing a method that does not result in death or choosing a time when the attempt is likely to be discovered.

The risk of dying by suicide increases with each suicide attempt, and suicide attempts are the best predictors of completed suicides. In regard to the prevalence and lethality of suicide, in 2001, the National Institute of Mental Health estimated that suicide accounted for over 30,622 deaths in the United States (U.S.) that year. Indeed, suicide was the 11th leading cause of death, with a rate of 10.7 deaths per 100,000 persons.

Globally, the problem of suicide is even greater, with the World Health Organization (WHO) estimating in the year 2000 that one million people committed suicide, at the rate of 16 deaths per 100,000 persons. On average, there is one death by suicide every 40 seconds worldwide. In addition, the global suicide rate has risen by 60% over the past 45 years to become the third leading cause of death.

Euthanasia, the Greek term for ‘‘good death,’’ refers to painless killing by act or omission. This practice, commonly known as mercy killing or assisted suicide, involves the termination of a life when that life is perceived as intolerable. Euthanasia is controversial because certain religious groups view assisted suicide as immoral or sinful, whereas others accept or advocate for the right to die. Some argue that because suicide is based on an inherently irrational decision, no one of sound mind can actually choose suicide, whether assisted or not.

Suicide Prevention Efforts

Suicide is most readily prevented when its warning signs are recognized by others, because few suicidal individuals voluntarily state their suicidal intentions or actively seek help. Indeed, many suicidal individuals experience an internal struggle about self-expression because they tend to turn negative feelings such as sadness and anger inward.

Furthermore, many mute their need for help because their internalized negative emotions have turned into hopelessness or shame. Still others, particularly people from cultures such as Africa and Asia, fail to verbalize their suicidal feelings because they experience their pain in the form of physical, rather than emotional symptoms. The most common signs of suicide are statements such as ‘‘I can’t go on,’’ or ‘‘I don’t know what will become of me.’’

An important facet of effective prevention is the provision of training to those most likely to have contact with suicidal individuals, such as their physicians, their friends and their family. In suicide prevention training, people are informed about how to identify signs of suicidality, and are encouraged to routinely ask about suicidal intent. Questions should be about whether the person is thinking about suicide, the plan (if any) for committing suicide, progress (if any) in assembling the means for implementing the plan, and the time frame for carrying out the plan. Improved mood states should also be carefully monitored. Suicidal individuals who have been visibly depressed may become more cheerful shortly before committing suicide.

Gender, Age and Ethnicity

Men are four times more likely than women to die by suicide, despite the fact that women are three times as likely as men to engage in suicide attempts. This gender disparity in suicide rate is partly due to gender preferences regarding suicide methods. With the exception of firearms, which are frequently chosen by both women and men (accounting for 55% of all suicides), men typically use more violent means to commit suicide, such as drowning, hanging, or knives, whereas women are more likely to use less lethal means, such as medication overdose.

Both the overall suicide rate and gender disparities increase with age. For youths, the suicide rate rises from 1.3 deaths per 100,000 persons for 10–14 year olds to 7.9 deaths per 100,000 persons for 15–19 year olds and 12 deaths per 100,000 persons for 20–24 year olds. Gender ratios also become more disparate with age, with a male–female ratio of 3:1 for 10–14 year olds, 5:1 for 15–19 year olds, and 7:1 for 20–24 year olds. Adolescent groups are also at-risk for committing copycat suicides after being exposed to reports of a suicide. At highest risk for suicide are adults over age 65, who committed 18% of all U.S. suicides in the year 2000.

In regard to ethnicity, in the U.S., Whites and Native Americans are considered to be at high-risk for suicide, while Hispanics, Asians and African Americans considered to be at lower-risk. Currently, no statistics exist to gauge suicide risk for gay, lesbian, and bisexual groups. White males over age 85 are at the highest risk for suicide, with a rate of 54 deaths per 100,000 persons, a rate more than five times the national average.

Seasonal Changes

Fluctuations in suicide rates are associated with seasonal changes. Suicide rates are highest during springtime and lowest during the winter. Many people postpone suicide until after holidays such as Christmas, have passed, thus lowering the suicide rate during major holidays. This is also true of shorter breaks, including weekends; suicide rates spike on Mondays and then decline until the end of the following weekend. Predictably, suicide rates also spike on New Year’s Day, the official end of the winter holidays. Rates of suicide attempts show the same patterns.

Psychiatric and Medical Illness

Individuals suffering from psychiatric illnesses are at a greatly increased risk for both attempted and completed suicide. Over 90% of all suicides have a history of psychiatric illness. In particular, individuals with Major Depressive Disorder and/or Alcohol Abuse are at the highest risk for committing suicide. Indeed, in the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), one of the criteria for Major Depressive Disorder is listed as, ‘‘Recurrent thoughts of death (not just a fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide.’’ Individuals with other mood disorders, such as Bipolar Disorder, are also at a heightened risk of suicide. The same is true for individuals with Borderline Personality Disorder and Schizophrenia, although their suicides may often be the result of co-existing depression.

There is a higher suicide risk associated with specific medical illnesses (including spinal cord injuries, multiple sclerosis, and AIDS), but this increased risk largely depends on how the individual reacts to the medical illness.

Many physically ill individuals who commit suicide are first diagnosed with a psychiatric illness, such as depression. Life stressors, such as grief, loss of income, and medical illnesses, do not inherently increase suicide risk; rather, stressful life events and one’s negative psychological reactions to those life events combine to additively increase risk.

Cultural Differences

The number of resources available for suicidal individuals varies by society because different cultures maintain diverse views on the significance of suicide. For example, the U.S. considers suicide a major problem and therefore provides a large network of services. These include 24-hour crisis hotlines, mental health referral sites and agencies, and school-based intervention teams.

In other countries, views on suicide range from concern or even fear to acceptance or even reverence. Societies that fear and abhor suicide consider open discussion of suicide as taboo, and keep information about suicides hidden.

Still others consider suicide a low priority or may view suicide to be noble under certain conditions. For example, in Japan suicide is sometimes perceived as a way to preserve or salvage honor. Shamed individuals can practice Seppuku (also known as Hara-kiri) by falling onto swords and dying to regain their honor.

Suicide can also be perceived as a way to advance a political or religious cause. This is the case for both suicide-bombers (acts of terrorism) and military divisions that undertake suicide missions to attack their enemies (such as Kamikaze pilots).

In efforts to create a universal conceptualization of suicide, strict definitions exclude deaths that are motivated by goals other than pure self-destruction. By these standards, deaths to regain honor, to express protest or to advance religious or political causes are not considered suicides.

Suggested Reading

Ellis, T. E., & Newman, C. F. (1996). Choosing to live: How to defeat suicide through cognitive therapy. Oakland, CA: New Harbinger.
Jacobs, D. G. (Ed.) (1999). The Harvard medical school guide to suicide assessment and intervention. San Francisco, CA: Jossey-Bass.
Jamison, K. R. (2000). Night falls fast: Understanding suicide. New York, NY: Random House

References

C. S. Clauss-Ehlers (Ed.), Encyclopedia of Cross-Cultural School Psychology, DOI 10.1007/978-0-387-71799-9, Springer Science+Business Media LLC 2010

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