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What
should you do if someone tells you they are
thinking about suicide?
If someone tells you they are thinking about
suicide, you should take their distress
seriously, listen non-judgmentally, 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.
What are the most common methods of
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.
Why do men commit suicide more often than
women do?
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. Men and women use
different suicide methods. Women in all
countries are more likely to ingest poisons than
men. In countries where the poisons are highly
lethal and/or where treatment resources scarce,
rescue is rare and hence female suicides
outnumber males.
Who is at highest risk for suicide in the
U.S.?
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.
Are gay and lesbian youth at high risk for
suicide?
With regard to completed suicide, there are
no national statistics for suicide rates among
gay, lesbian or bisexual (GLB) persons. Sexual
orientation is not a question on the death
certificate, and to determine whether rates are
higher for GLB persons, we would need to know
the proportion of the U.S. population that
considers themselves gay, lesbian or bisexual.
Sexual orientation is a personal characteristic
that people can, and often do choose to hide, so
that in psychological autopsy studies of suicide
victims where risk factors are examined, it is
difficult to know for certain the victim's
sexual orientation. This is particularly a
problem when considering GLB youth who may be
less certain of their sexual orientation and
less open. In the few studies examining risk
factors for suicide where sexual orientation was
assessed, the risk for gay or lesbian persons
did not appear any greater than among
heterosexuals, once mental and substance abuse
disorders were taken into account.
With regard to suicide attempts, several
state and national studies have reported that
high school students who report to be
homosexually and bisexually active have higher
rates of suicide thoughts and attempts in the
past year compared to youth with heterosexual
experience. Experts have not been in complete
agreement about the best way to measure reports
of adolescent suicide attempts, or sexual
orientation, so the data are subject to
question. But they do agree that efforts should
focus on how to help GLB youth grow up to be
healthy and successful despite the obstacles
that they face. Because school based suicide
awareness programs have not proven effective for
youth in general, and in some cases have caused
increased distress in vulnerable youth, they are
not likely to be helpful for GLB youth either.
Because young people should not be exposed to
programs that do not work, and certainly not to
programs that increase risk, more research is
needed to develop safe and effective programs.
Are African American youth at great risk
for suicide?
Historically, African Americans have had much
lower rates of suicides compared to white
Americans. However, beginning in the 1980s, the
rates for African American male youth began to
rise at a much faster rate than their white
counterparts. The most recent trends suggest a
decrease in suicide across all gender and racial
groups, but health policy experts remain
concerned about the increase in suicide by
firearms for all young males. Whether African
American male youth are more likely to engage in
"victim-precipitated homicide" by
deliberately getting in the line of fire of
either gang or law enforcement activity, remains
an important research question, as such deaths
are not typically classified as suicides.
Is suicide related to impulsiveness?
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.
Is there such a thing as
"rational" 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.
What biological factors increase risk for
suicide?
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.
Can the risk for suicide be inherited?
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.
Does depression increase the risk for
suicide?
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 percent 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 percent). Those
treated for depression as inpatients following
suicide ideation or suicide attempts are about
three times as likely to die by suicide (6
percent) as those who were only treated as
outpatients. There are also dramatic gender
differences in lifetime risk of suicide in
depression. Whereas about 7 percent of men with
a lifetime history of depression will die by
suicide, only 1 percent of women with a lifetime
history of depression will die by suicide.
Another way about thinking of 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 percent 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.
Does alcohol and other drug abuse increase
the risk for suicide?
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 was
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 non-traffic injury deaths
associated with alcohol intoxication, over 20
percent were suicides.
In studies that examine risk factors among
people who have completed suicide, substance use
and abuse occurs more frequently among youth and
adults, compared to older persons. For
particular groups at risk, such as American
Indians and Alaskan Natives, depression and
alcohol use and abuse are the most common risk
factors for completed 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.
What does "suicide contagion"
mean, and what can be done to prevent it?
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.
Is it possible to predict suicide?
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.
December 1999
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