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 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.
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. Several explanations have been
offered: a) Completed suicide is associated with aggressive behavior that
is more common in men, and which may in turn be related to some of the
biological differences identified in suicidality. b) 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. More research is needed
on the social-cultural factors that may protect women from completing
suicide, and how to encourage men to recognize and seek treatment for
their distress, instead of resorting to suicide.
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. Why are rates
so high for this group? White males are more deliberate in their
suicide intentions; they use more lethal methods (firearms), and are less
likely to talk about their plans. It may also be that 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 with a
depressive illness that was not detected. This has led to research
efforts to determine how to best improve physicians’ abilities to detect
and treat depression in older adults.
Do school-based suicide awareness programs prevent youth suicide?
Despite good intentions and extensive efforts to develop suicide
awareness and prevention programs for youth in schools, few programs have
been evaluated to see if they work. Many of these programs are
designed to reduce the stigma of talking about suicide and encourage
distressed youth to seek help. Of the programs that were evaluated,
none has proven to be effective. In fact, some programs have had
unintended negative effects by making at-risk youth more distressed and
less likely to seek help. By describing suicide and its risk
factors, some curricula may have the unintended effect of suggesting that
suicide is an option for many young people who have some of the risk
factors and in that sense “normalize” it—just the opposite message
intended. Prevention efforts must be carefully planned, implemented
and scientifically tested. Because of the tremendous effort
and cost involved in starting and maintaining programs, we should be
certain that they are safe and effective before they are further used or
promoted.
There are number of prevention approaches that are less likely to have
negative effects, and have broader positive outcomes in addition to
reducing suicide. One approach is to promote overall mental health
among school-aged children by reducing early risk factors for depression,
substance abuse and aggressive behaviors. In addition to the
potential for saving lives, many more youth benefit from overall
enhancement of academic performance and reduction in peer and family
conflict. A second approach is to detect youth most likely to be
suicidal by confidentially screening for depression, substance abuse, and
suicidal ideation. If a youth reports any of these, further
evaluation of the youth takes place by professionals, followed by referral
for treatment as needed. Adequate treatment of mental disorder
among youth, whether they are suicidal or not, has important academic,
peer and family relationship benefits.
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% 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 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%
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 minum-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 nontraffic 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.
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