What is suicide?

Causes and Symptoms

Suicide is the deliberate taking of one’s own life. Most often, suicidal individuals are trying to avoid emotional or physical pain that they believe they cannot bear; sometimes, they are very angry and take their lives to lash out at others. Suicide is seen as a solution to an otherwise insoluble problem. In the United States in 2011, according to the Centers for Disease Control and Prevention (CDC), 39,518 individuals committed suicide and approximately 487,700 received medical treatment for self-inflicted injuries. The World Health Organization (WHO) reported an estimated 804,000 suicides worldwide in 2012. Women attempt suicide more often than men, but men complete suicide more often than women because men tend to use more lethal means, such as a gun. In high-income countries, adolescents and the elderly are high-risk groups, while in low- and middle-income countries, adults in middle age are at greater risk, according to WHO.

When an individual contemplates suicide to avoid the physical pain of a terminal illness rather than because of a psychiatric disorder, this form of suicidal thought is often called “rational” suicide. Rather than implying that this form of suicide is appropriate, moral, or legal, this merely indicates that the suicidal thoughts do not arise from a disorder (nonrational). Social views on rational suicide vary by culture. In a 1999 study by Steven Stack, based on data published by the World Values Study Group in 1994, support for rational suicide was highest in China, Japan, and Scandinavian countries such as Finland, Denmark, and the Netherlands and lowest in predominantly Catholic countries such as Argentina, Brazil, Chile, Ireland, and Poland. American public support for rational suicide fell somewhere in the middle.

Most suicidal people encountered by physicians, psychologists, social workers, and other mental health professionals experience suicidal thoughts as a result of a psychiatric disorder. The suicidal thoughts and impulses are seen as symptoms of the underlying disorder and require treatment just like any other symptom. The treatment may involve protecting the person against his or her suicidal actions, even to the point of involuntary commitment to a mental hospital.

The rationale behind society’s willingness temporarily to deny suicidal individuals’ usual civil rights by involuntary commitment is that they are considered to be not “acting in their right mind” by virtue of their mental illness. Thus, they deserve the protection of society until their illness is treated. In fact, suicidal thoughts usually do abate when suicidal patients are treated. The vast majority of these individuals are appreciative afterward; they are glad that they were prevented from killing themselves, as they no longer wish to do so.

The most common mental illness that causes suicidal thoughts is depression. In fact, suicidal thoughts are considered to be a symptom of clinical depression. Other psychiatric disorders associated with suicidal ideation include anxiety disorders such as panic disorder, psychotic disorders such as schizophrenia, substance use disorders such as alcohol dependence, and certain personality disorders such as borderline personality disorder.

Although suicide may occur at any time of the year, there is a seasonal variation in its peak incidence. Suicides are most common in both men and women in late spring and early summer; a number of studies have attributed this to increases in temperature, levels of sunlight, and/or humidity, but others have disputed the link. Studies have also shown that women, unlike men, have a second peak in suicide rates in the fall.

Suicide appears to have multiple factors involved in its etiology. There are biological, psychological, social, and contextual factors that interact in a complex way to contribute to the causes of suicide in any given individual. The biological factors include genetic contributions to the development of psychiatric disorders such as clinical depression. This may be attributable in part to problems in the neurotransmitter systems in the brain, such as those that control levels of serotonin and dopamine.

Alcohol and other substances of abuse may also cause suicidal ideation. Suicidal thoughts may occur while the individual is using, intoxicated, or in withdrawal. Paradoxically, suicidal thoughts may also arise while the patient is taking antidepressant medications. Fortunately, this side effect is uncommon, and most antidepressant medications do not have such effects. The fact that suicidal thoughts may occur even when on medication, however, underscores the need for individuals taking medications to stay in regular contact with the prescribing physician and to never discontinue their medication without medical consultation. If family members observe a depressed individual who takes medication becoming more depressed, hostile or angry, or suddenly happy or relieved, or if the individual has no apparent response to the medication, then it would be wise to consult with the prescribing physician. This is especially true for family members of children or elders on antidepressant medication.

Psychological factors contributing to suicide include a depressed and/or anxious mood, hopelessness, and a loss of normal pleasure in life activities. Chronically depressed people often have diminished problem-solving skills during periods of depression and can see no way out of their difficulties; suicide is seen as the only solution. There are also personality characteristics that contribute to suicide. In women, borderline personality disorder is often associated with suicide attempts. This disorder is characterized by widely fluctuating moods, rages, feelings of emptiness or boredom, and unstable relationships.

The social factors involved in suicide include cultural acceptance or rejection of suicide. Historically, Japanese people have accepted ritual suicide within their culture and have somewhat sanctioned suicide as a response to a severe loss of face or social esteem. This does not mean that Japanese culture embraces suicide, but rather that the history contributes to cultural norms where this is thought of as an option for dealing with shame. Similarly, in 2002, the Dutch government legalized euthanasia and physician-assisted suicide in certain cases of terminal illness. In contrast, most Americans have a more negative view of the act of suicide, although the states of Oregon, Vermont, and Washington have passed laws permitting physician-assisted suicide (but not euthanasia). Other social factors that increase the likelihood of suicide include social instability, divorce, unemployment, immigration, and exposure to violence as a child. In the United States, European Americans commit suicide more often than African Americans. Native Americans have a high incidence of suicide. In general, good social support reduces the risk of suicide.

Some patients engage in suicidal gestures; that is, they say they want to kill themselves and take actions such as swallowing some pills or superficially cutting their wrists, but there is no real intention to die. They act this way as a cry for help. For some, this may be the only way to receive attention for what troubles them. Unfortunately, the suicide gesture may go awry, and unintended death may occur. Anyone who speaks of suicide or engages in what may appear to be a gesture should be taken seriously.

Most people who are suicidal have ambivalent feelings: part of them wants to die, part does not. This is one of the reasons that the majority of suicidal people tell others of their intention in advance of their attempts. Most visit their personal physician in the months prior to the suicide. Adolescents sometimes hint at their wish to die by giving away their prized possessions prior to an attempt.

Contextual factors, or the circumstances in which people find themselves, can also contribute to individuals attempting suicide. Access to means of self-harm, such as weapons or drugs, can increase the likelihood of a suicide attempt. Similarly, physical isolation from others can also increase the odds, as there is no one to readily intervene. Even painful emotional or physical states, such as exhaustion or a state brought on by substance use, can set the stage for impulsive behavior and increase the likelihood of suicide attempts. However, simply talking to someone about suicidal thoughts will not cause a person to commit suicide, and in fact this may be a way to get help from a professional.

Anyone experiencing suicidal thoughts should be thoroughly evaluated by a professional trained in the assessment of suicidal patients. If the risk of suicide is considered to be high enough, the patient will have to be protected. This may require hospitalization, either voluntary or involuntary. It may mean removing suicidal means from that person’s environment, such as removing guns from the home. Having someone stay with the patient at all times may be required. These steps should be individualized, taking into account the patient’s situation.

Treatment of the underlying cause of the suicidal ideation is very important. Depression and anxiety can be treated with medications and/or psychotherapy. There are treatment programs for alcoholism and drug abuse. Usually, successful treatment of the underlying psychiatric disorder results in the suicidal thoughts going away.

While they await the resolution of the suicidal ideation, patients need to be offered support and hope. Sometimes a “no suicide” contract is helpful. This is simply a commitment on the part of the patient not to act on any suicidal thoughts and to contact the health professional if the urges become worse. While this contract may be written down, it is usually verbal.

Suicide prevention includes the early detection and management of the mental disorders associated with suicide. Because social isolation increases the risk of suicide, patients should be encouraged to develop and actively maintain strong social supports such as family, friends, and other social groups (e.g., church, clubs, or sports teams).

It may also be helpful to provide counseling to teenagers after an acquaintance has committed suicide, as this may prevent social contagion and suicide clusters. A suicide cluster is when several individuals, often teenagers, commit suicide after learning of the suicide of an acquaintance or a person who is attractive to them, such as a music or film star. Suicide clusters have increased among the young.

Family members of a suicide victim often go through a grieving process that is more severe than that which occurs after death from other causes. The stigma of suicide and mental illness is strong, and surviving family members often have greater feelings of both guilt and abandonment. Family survivors also have increased psychosomatic complaints, behavioral and emotional problems, and risk of suicide themselves. Referral to a suicide survivor group may be helpful.

Treatment and Therapy

An understanding of the causes, detection, and treatment of suicide has led to the development of a number of suicide hotlines and suicide prevention centers. There is evidence that after these support groups are introduced into a community, the suicide rate for young women decreases. It is not yet known if they have any effect on other groups, such as young men or the elderly.

Most people who contemplate suicide do not seek professional treatment even if they tell people around them of their suicidal ideas. Thus, it is important for physicians, clergy, teachers, parents, and mental health workers to remain alert to the possibility of suicidal thoughts in those in their care. Someone who is depressed or very anxious should be asked about suicidal thoughts. Such a question will not plant the idea in the person's head, and he or she may feel relieved after being asked. Once someone with suicidal ideation is identified, evaluation and treatment should proceed quickly. The following sample composite cases illustrate the application of the concepts described in the overview.

Mary is a seventeen-year-old senior in high school. She is from a broken home and was severely abused by her father prior to her parents’ divorce ten years ago. Her teachers think that she is a bright underachiever who has a rather dramatic personality. Her friends see her as moody and easily angered. Her relationships with boyfriends are intense and always end with deep feelings of hurt and abandonment. Her mother is best described as cold, aloof, and preoccupied with herself.

Mary is brought to the school counselor by one of her friends when Mary threatens to kill herself and superficially scratches her wrists with a safety pin. The counselor learns that Mary has just broken up with her boyfriend, a young man at a local junior college, and is devastated. When she tried to tell her mother about it, her mother seemed uninterested and said that Mary always makes too much of such little things. It was the next morning that she scratched herself in front of her friend.

While more information is needed, this case illustrates a suicidal gesture. In this case, Mary does not want to die, but she wants someone to realize how distressed she is. She feels rejected by her boyfriend and then by her mother. Suggestions that this is a gesture rather than a serious suicide attempt include the superficial, nonlethal means (scratching with a safety pin) and the likelihood of discovery (done in front of a friend).

Here is a second case. Tom is a forty-eight-year-old accountant. He is separated from his wife and three children and lives alone in an apartment. He has no real friends, only drinking buddies. Like his father and two uncles, Tom is an alcoholic. Each day after work, he stops at his favorite bar and drinks between eight and twelve beers.

He is brought to the emergency room of the local hospital by the police, who found him sitting on the steps of a church, sobbing. He threatened to kill himself if his wife did not take him back. The emergency room doctor noted the strong odor of alcohol on his breath and ordered a blood alcohol test, which showed that he was legally intoxicated. Tom insisted that he would kill himself by running in front of a moving bus if he could not be with his family. The emergency room doctor had Tom’s belt, pocketknife, and other potentially dangerous items taken from him and arranged for a staff member to sit with him until he was sober. Six hours later, his blood alcohol had returned to near zero. Tom no longer felt despondent and had no more suicidal thoughts. He was embarrassed by his statements a few hours before. An alcoholism counselor was called, and outpatient treatment for his alcoholism was arranged.

This case illustrates suicidal ideation caused by alcohol intoxication. As often happens, the suicidal ideation resolves when the patient becomes sober. The primary treatment is for the underlying addictive disorder.

Here is a third case. Sally is a fifty-three-year-old married mother of two. She is a part-time hairdresser and normally a very active, happy person. For the past three weeks, however, she has gradually lost all interest in her job, her children, her home, and her hobbies. She feels irritable and sad most of the time. Although she is tired, she does not sleep well at night, waking up very early each morning, unable to return to sleep. She is worried by the fact that she is having intrusive thoughts of killing herself. Sally imagines she could end all this dreariness by overdosing on sleeping pills and never waking up. She is a strict Catholic and knows it is against her religion to commit suicide. She calls her parish priest.

After a brief conversation, her priest meets her at the office of a psychiatrist who acts as a consultant for the diocese. The psychiatrist diagnoses major depression as the cause of Sally’s suicidal ideation. She has a good social support network, so the psychiatrist decides to treat her as an outpatient and has her agree to a “no suicide” contract. Sally is also started on antidepressant medication, which gradually lifts her depression over a period of two to three weeks. Simultaneously, her suicidal thoughts leave her.

This case illustrates suicidal thoughts caused by depression. If Sally had been more depressed or her suicidal urges stronger, she would probably have needed hospitalization. If she had required hospitalization and had refused to go voluntarily, the psychiatrist could have had her committed according to the laws of the state where he practiced. Most states require a signed statement by two physicians or one physician and a licensed clinical psychologist. They must attest that the patient is a danger to him- or herself and that no less restrictive form of treatment would suffice.

Finally, here is a fourth case. Harry is a sixty-seven-year-old resident of a hospital, where he has been for the past two years. He has a serious neurological disorder called amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease. It has caused progressive weakness such that he cannot even breathe on his own. Harry is permanently connected to a respirator attached to a tracheotomy tube in his throat. He has few visitors and mostly stares off and thinks.

Harry tells his nurse that he is “sick of it all” and wants his doctors to disconnect him from the respirator and let him die. His neurologist requests a psychiatric evaluation. The psychiatrist confirms the patient’s wish to die. There is no evidence of dementia or other cognitive disorder, nor is the patient showing any evidence of a mental illness. Subsequently, a meeting is called of the hospital ethics committee to make recommendations. Members of the committee include physicians, nurses, an ethicist, a local minister, and the hospital attorney.

This case illustrates a difficult example of a rational suicide request. The patient has a desire to die and is not suffering from any mental disorder. In this case, he is requesting not to take his own life actively but to be allowed to die passively by removal of the respirator. Some people do not consider this to be suicide at all. They make a distinction between passively allowing a natural process of dying to occur and actively taking one’s own life. If this patient requested a lethal overdose of potassium to be injected into his intravenous tubes, such action would be considered suicide and ethically different. In either event, these matters are more ethical, social, and legal than psychiatric.

Perspective and Prospects

Throughout history, there have been numerous examples of suicide. In Western culture, early views on the subject were mainly from a moral perspective, and suicide was viewed as a sin. Mental illness in general was poorly understood and often stigmatized as weakness of character, possession by evil spirits, or willful bad behavior. Even though society now has a better medical understanding of mental illness, there is still a stigma attached to mental illness and to suicide. This stigma contributes to underdiagnosis and undertreatment of suicidal individuals, as many sufferers are reluctant to come forth with their symptoms.

Suicide remains an important public health problem. In 2011, it was the tenth most common cause of death in the United States overall and the third most common cause among those between the ages of ten and twenty-four. Each year, there are more than thirty thousand known suicides in the United States. The actual incidence may be higher because an unknown number of accidental deaths or untreated illnesses may actually be unidentified suicides. For every suicide death, between eight and twenty-five other individuals attempt suicide.

Unfortunately, most cases of suicidal ideation never come to the attention of health professionals. Therefore, when someone talks of suicide, a high index of suspicion should be maintained. People who express suicidal thoughts should be taken seriously and thoroughly evaluated. Increased levels of awareness of suicide may help improve detection and treatment of this potentially preventable cause of death. Research in this area continues to focus on prevention, early identification, and treatment for individuals who are distressed.

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