Suicide 

Suicide ranks as the tenth leading cause of death in the United States (see the figure below).^{[1, 2]} Globally, an estimated 700,000 people will take their own lives annually.^[3] In certain populations, such as adolescents and young adults, suicide constitutes 1 of the top 3 causes of death. This phenomenon is even more compelling because, in many instances, suicides can be prevented. Therefore, clinicians must recognize the risk factors for suicide as a way of intervening in a self-destructive event and cycle.

This article examines suicide and will discuss the following:

• The basic definitions as applied to self-destructive activities and events
• Risk factors that can alert the clinician to early warning signs of suicide
• Interventions if a person's attempt at suicide is imminent
• The diagnosis and treatment of the underlying mental disorder causing the self-destructive behavior
• Appropriate actions for a clinician if a person being treated does commit suicide

Depression, isolation, previous suicide attempts, substance abuse, and serious mental illness rank as highly significant contributors for suicide. Swift and decisive interventions based on a thorough assessment can save lives. Yet, preventing a person from committing suicide is only the first step in the treatment of the suicidal patient.

Once it has been assured the patient is safe, the reasons for the self-destructive behavior must be determined. One must look for underlying causes. One must determine the mental illness of which the suicidal behavior is the manifestation. The diagnosis requires a complete psychiatric history and mental status examination. Once the mental illness has been determined, that dictates the appropriate treatment. Talking therapies help patients. In many instances, mediation can alleviate the symptoms of that mental illness. Finally, however, despite intervention, if the patient does commit suicide, a number of steps can and should be undertaken for the patient's family, other patients, the staff, and the therapist.

The top 15 causes of death (in person aged 1-85+ y) in the United States in 2007, according to the National Institute of Mental Health, are as follows^[4] :

• Heart disease - 615,616
• Malignant neoplasms - 562,795
• Cerebrovascular - 135,814
• Chronic lower respiratory disease - 127,875
• Unintentional injury - 122,387
• Alzheimer disease - 74,629
• Diabetes mellitus - 71,373
• Influenza and pneumonia - 52,492
• Nephritis - 46,304
• Suicide - 34,592
• Septicemia - 34,543
• Liver disease - 29,185
• Hypertension - 23,963
• Parkinson disease - 20,056
• Homicide - 17,984

Definitions

Suicide means killing oneself. The act constitutes a person willingly, perhaps ambivalently, taking his or her own life. Several forms of suicidal behavior fall within the self-destructive spectrum.

A completed suicide means the person has died. It is important not to use the term successful suicide; the goal is to prevent suicide and provide treatment.

A suicide attempt involves a serious act, such as taking a fatal amount of medication and someone intervening accidentally. Without the accidental discovery, the individual would be dead.

A suicide gesture denotes a person undertaking an unusual, but not fatal, behavior as a cry for help or to get attention.

A suicide gamble is one in which patients gamble their lives that they will be found in time and that the discoverer will save them. For example, an individual ingests a fatal amount of drugs with the belief that family members will be home before death occurs.

A suicide equivalent involves a situation in which the person does not attempt suicide. Instead, he or she uses behavior to get some of the reactions their suicide would have caused. For example, an adolescent boy runs away from home. He wants to see how his parents respond. Do they care? Are they sorry for the way that they have been treating him? It can be seen as an indirect cry for help.

Case study

Paul, aged 21 years, sits on the side of his bed and wonders if life is worth living. He is depressed because of a failed relationship with his now exgirlfriend. He has not been sleeping or eating well and has been drinking too much. With his college education, he wishes he would have a better job than working at a bookstore. His father committed suicide when Paul was age 10 years, at age 43 years. He owns a gun but does not have ammunition. He is Catholic and knows suicide is considered a sin. Yet, he just feels so bad and feels both hopeless and helpless. However, he likes classical music and loves writing, and he eventually would like to go to graduate school. He is ambivalent—he wants to die, and wants to live. He wonders if something is wrong with him and considers seeing his family doctor.

See also the following:

• Depression and Suicide
• Physician Suicide
• Bipolar Affective Disorder
• Depression
• Dysthymic Disorder
• Pediatric Depression
• Postpartum Depression

A number of factors correlate with serious suicide attempts and completed suicides, including the following:

• Medications
• Mental illness
• Sex
• Genetics
• Availability of firearms
• Life experiences
• Physical illness
• Economic instability and status
• Media and the Internet
• Psychodynamic formulation
• Other risk factors

An understanding of the causes of the suicidal behavior will not only clarify the roots of the self-destructive path but also help determine the appropriate treatment for the patient. Once the patient is safe, then the underlying dynamics can be addressed.

Note the figure below.

The HUNT I Study, which is a 20-year follow-up of sleeping problems and suicide in 75,000 Norwegian adults, concluded that sleeping problems are an indicator of suicide risk.^[5] This risk was due to sleeping problems as well as mixed anxiety and depression. Healthcare professionals should be aware of this risk in patients with sleeping disorders.

Medications

In recent years, a number of medications have been linked to suicidal behavior. These have prompted the US Food and Drug Administration (FDA) to requiring a warning on certain prescription medications, such as antidepressants, anticonvulsants, and analgesics.

Antidepressants

Initially, the FDA and studies connected antidepressants to childhood and adolescent self-destructive events and required a warning for those populations; however, Schneeweiss and colleagues found the same linkage for adults as well.^[6] The investigators reviewed data from all 287,543 residents of Canada's British Columbia, 18 years or older, who had been placed on an antidepressant between 1997 and 2005 and concluded the following: "Our finding of equal event rates across antidepressant agents supports the US Food and Drug Administration's decision to treat all antidepressants alike in their advisory. Treatment decisions should be based on efficacy, and clinicians should be vigilant in monitoring after initiating therapy with any antidepressant agent."^[6]

Anticonvulsants

In 2008, the FDA required a suicidal behavior warning be placed on anticonvulsants. In a 2010 exploratory analysis, Patorno and colleagues suggested that the use of gabapentin, lamotrigine, oxcarbazepine, and tiagabine, compared with the use of topiramate, may be associated with an increased risk of suicidal acts or violent deaths.^[7]

Pain medication

Tramadol is a narcoticlike pain reliever that, on May 26, 2010, received an FDA addition of a suicide risk warning (tramadol hydrochloride [Ultram] and tramadol hydrochloride/acetaminophen [Ultracet]).^[8] The FDA noted linkage between patients with emotional instability and suicidal ideation and increased self-destructive behavior with tramadol prescriptions.^[8]

Smoking cessation medications

Moore et al determined that the risk of depression and suicidal or self-injury behaviors is substantially increased and statistically significant with the use of varenicline. Risk were present but less with bupropion, and even less so with nicotine replacement. They suggest varenicline is unsuitable as a first-line agent to aid in smoking cessation.^[9]

Mental illness

Although mental illness is generally linked to premature deaths, certain mental illnesses carry with them remarkably high lifetime instances of suicide. In fact, 95% of people who commit suicide have a mental illness. Hospitalization for a psychiatric disorder is quite prevalent in the suicidal population,^[10] including people with any depressive disorder, manic-depressive illness (bipolar illness), schizophrenia, posttraumatic stress disorder (PTSD), phobias, substance abuse, delirium, and dementia, as well as certain genetic factors. In a general sense, mental illness all too often is an isolating experience, and that isolation correlates with suicide.

Each psychiatric disorder has its own distinctive mental status footprint. (A mental status review is designed to augment these mental statuses by paying particular attention to evaluating those persons' suicide potential [see Mental Status Review]).

Depression

Because depression involves a preoccupation with death, the twin killers of hopelessness and helplessness, and withdrawal, it is a major contributor to suicide. A dangerous time in depression occurs when a patient is coming out of the deepest part of the experience. At that point, these individuals can mobilize their newly acquired energy to take their own life.

The protracted and profound emotional roller coaster of manic-depressive illness puts the person at risk both during the depressive phase and in the psychosis of mania. Suicide is a particular risk when executive functions and judgment have been compromised by bipolar disorder.^[11] In particular, men with bipolar disorder have an increased risk for suicide.^[12]

One important consideration in the treatment of depression is that selective serotonin reuptake inhibitors (SSRIs) have a lower rate of fatal overdoses than tricyclic antidepressants (TCAs).^[13]

Shah et al found that in adults younger than 40 years, depression and history of attempted suicide are significant independent predictors of premature cardiovascular disease and ischemic heart disease in both males and females.^[14]

See also Depression and Suicide, Depression, and Bipolar Affective Disorder.

Schizophrenia

Schizophrenic patients are at a significantly high risk for suicide (see Schizophrenia). They may experience hallucinations, often auditory, such as voices commanding them to kill themselves (command hallucinations). In addition, these individuals may, in the context and as a result of their illness, become depressed; they realize that they are different from others.

Persons with schizophrenia may also have moments of insight during which they realize that they may achieve some life goals that others can accomplish. Individuals who are considered highly functional seem to be at high risk for suicide, perhaps because of their ability to appreciate how they are and how they are different, both from others and from what they wish their lives might be.

Finally, the suspicions and fears associated with schizophrenia may promote isolation and withdrawal.

The pronounced high rate of suicide in patients with schizophrenia is actually higher when physical comorbidity or substance abuse is also present.^[15]

Anxiety disorders

Obsessive-compulsive disorder (OCD) and phobic disorders have symptoms that make suicide a possibility. Persons struggling with these symptoms feel frightened, terrorized, isolated, and physically paralyzed by feelings of anxiety, panic, and dread that often seem inexplicable. In many instances, people feel the symptoms are growing, expanding, and incapacitating.

A study by Katz et al has shown that panic attacks and panic symptoms in individuals with a major mood disorder meeting DSM-IV criteria may have an increased risk of suicidal ideation, which may progress to suicide attempts, especially in those individuals characterized by prominent catastrophic cognitions.^[16]

For example, a woman with agoraphobia who becomes progressively more isolated and depressed by her inability to leave her home (see Anxiety Disorders, Obsessive-Compulsive Disorder, and Social Phobia).

Posttraumatic stress disorder

Survivors of trauma (eg childhood sexual abuse, recent physical devastation, physical/emotional abuse) struggle with flashbacks and nightmares. These individuals frequently alternate between periods of hypervigilance and periods of psychic numbing.

Veterans of the wars in Iraq and Afghanistan experience a high rate of PTSD and have a historically high rate of suicide.^{[17, 18, 19]} They have feelings of being damaged and feelings of guilt. As a result, they have a high rate of suicide.

Postdeployment readjustment problems affecting veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) are well-documented, but the possible relationship of readjustment stressors to the recent increase in military suicide is not. Kline et al found that after adjusting for mental health and combat exposure, veterans with the highest number of readjustment stressors had a 5.5 times greater risk of suicidal ideation than those with no stressors. This suggests that suicide prevention efforts that more directly target readjustment problems in returning OEF/OIF veterans are needed.^[20]

See Posttraumatic Stress Disorder.

Substance abuse

Substances can contribute to self-destructive behaviors in all 3 phases of their use—intoxication, withdrawal, and chronic usage. A depressed person commonly becomes acutely suicidal after a few drinks. Similarly, some people can become suicidal after ingesting lysergic acid diethylamide (LSD). Still others encounter depression during substance withdrawal and respond with killing themselves.

A person with chronic alcohol and drug use often experiences a number of major losses, such as a job, spouse, and family, and these in turn contribute to becoming suicidal (see Alcoholism; Opioid Abuse; Toxicity, Cocaine; and Hallucinogens. Women with substance abuse disorders have an increased risk for suicide.^[12]

Even those in drug recovery programs remain at risk. For example, persons in opiate dependency programs, especially those with chronic pain, those with the availability of firearms, those who use other street drugs, and those new to the program are at particular risk.^[21]

In a US study, Bohnert et al found that suicide and overdose are connected yet distinct problems. Patients who have both a history of suicide attempts and nonfatal overdoses may have poor psychological functioning, as well as a more severe drug problem.^[22]

The physical and mental health effects associated with methamphetamine (MA) use has been documented; however, little is known about the effects of injection MA and suicidal behavior. The Vancouver Injection Drug Users Study (VIDUS) elicited information regarding sociodemographics, drug use patterns, and mental health problems, including suicidal behavior. Of 1873 eligible participants, 149 (8%) reported a suicide attempt. MA injection was associated with an 80% increase in the risk of attempting suicide, suggesting that individuals who inject MA should be monitored for suicidal behavior.^[23]

Delirium and dementia

Delirium and dementia involve loss of memory, disorientation, hallucinations, delusions, and poor judgment (see Delirium and Vascular Dementia). These conditions often lead to self-destructive behavior. For example, an accountant slowly starts to have difficulty remembering numbers and performing addition problems. Although others view these problems as minimal, he feels he is losing his mind and career and takes his life.

Bulimia

Bulimia has been accompanied by suicidal activity. Predisposing factors include feelings of loneliness, stimulant use, family history of psychiatric disorders, childhood abuse, and difficulty dealing with the public.^[24]

See Bulimia Nervosa and Emergent Management of Bulimia.

Sex

There is a distinct difference in suicide rates by sex. Men have a significantly higher rate of completed suicides than women. There are nearly 4 times the number of completed suicides for men than for women. However, women have a much higher rate of suicide attempts.^[25] Often, women select methods, such an overdose of medication, that allow more time for intervention. Men frequently use methods such as firearms, which are much more lethal.

Females more often use poison when attempting suicide. A study by Hoon et al investigated the risk factors associated with the repetition of deliberate self-poisoning. The associated factors for repeat suicide attempt were sex (female), living without a family, using antidepressants, and a history of psychiatric treatment. Early psychological intervention and close observation is required for patients meeting these criteria.^[26]

Note the graph below.

Genetics

Some authorities believe that genetic factors alone may be involved, that suicide runs in families, and that having a relative who commits suicide is indeed a risk factor. Therefore, a family history of suicide is very significant. Careful assessments of family history of mental illness and suicide should be a routine aspect of patient evaluation.

Studies continue to show the gene connection in suicidal behavior. Genes related to serotonin have been implicated in histories of second suicide attempts.^[27] Many of the discussed mental illnesses (eg, manic-depressive illness) are not only risk factors for suicide but also have strong genetic components.

Family history

A family history of suicidal behavior represents a significant risk factor for the same behavior in offspring. In some families, suicide constitutes a dynamic to deal with crises. Geulayov et al reviewed the literature on these associations and found such a relationship. They also determined the association is stronger with maternal suicidal behavior versus paternal suicidal behavior and the risk is increased in children versus adolescents or adults.^[28]

Availability of firearms

The leading method of suicide remains firearms (see the following image).^{[29, 2]} When a person with a depressed mood consumes alcohol and has a handgun available, the situation can easily turn lethal. Of 34,598 completed suicides, 17,352 used guns.^[2] Therefore, a psychiatrist must not only inquire into the patient's suicidal ideation and plans but also the presence of firearms. Clinicians also must know their state statues concerning persons with mental illness possessing firearms.^[30] Of interest, the limiting of the purchasing of firearms by local and state background checks has decreased the rate of suicide by guns.^[31]

Data from the National Institute of Mental Health (NIMH) on the differences between men and women and the method of suicide are as follows^[25] :

• Suicide by firearms - Males (56%), females (30%)
• Suicide by suffocation - Males (24%), females (21%)
• Suicide by poisoning - Males (13%), females (40%)

Physical illness

Suicide is often encountered in patients who have a severe medical problem. The risk for suicide increases if the patient faces pain in the face of protracted, painful, a progressively debilitating disease.

For example, patients undergoing dialysis for end-stage renal disease have a higher rate of suicide than that of the general population.^[32] Other diseases conferring higher risk include chronic obstructive pulmonary disease (COPD), cancer, human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS), quadriplegia, multiple sclerosis, severe whole-body burns, and chronic heart failure.

Asthma has also been linked to suicide, particularly in young people.^{[33, 34]} The combination of cancer and age is particularly lethal.^[35] Persons experiencing increasing intractable pain are at particularly high risk for suicide.

Life experiences

Certain recent life events can precipitate suicidal behavior. These include losses in the romantic area, such as the termination of a love relationship or a divorce, a job termination, or a pet. The acute loss can be very devastating, as evidenced by the case of an emergency department (ED) nurse who was fired for her drug use and immediately went home and committed suicide.^[36]

A number of past life events are also linked to the act of committing suicide. The most important is suicide by a family member or a friend. Not infrequently, history of a father, mother, or sibling committing suicide correlates with suicide by another member of that family. For example, when a boy was 5 years old, he witnessed his mother kill herself by shooting herself in the head. Later, after several attempts, he killed himself. Another young child killed himself because he wanted to "join mommy in heaven." Family members had told him that after his mother died, she was in heaven with God. In his view, his suicide allowed him to be with her again.

Suicides by friends provoke others to duplicate the event. Especially in adolescents, suicide has a contagious aspect.^[37] Not uncommonly, one suicide in a high school is followed by other suicides or attempts.

As discussed earlier, persons with PTSD are particularly vulnerable to suicide. These individuals may have a history of physical, emotional, or sexual abuse. Damage to the person leads to self-destructive actions.

A study examining the possible link between trauma exposure and suicidal behavior was conducted with 4351 adult South Africans from 2002-2004 as part of the World Health Organization (WHO) World Mental Health Surveys. Sexual violence and having witnessed violence were significant predictors of lifetime suicide attempts. Future research is needed to better understand how and why these experiences in particular increase the risk of suicidal outcomes.^[38]

Bullying is another past life experience that has emerged as a correlate to suicidal behavior, and attention must be paid to a personal history of bullying victimization in the suicide assessment. In a landmark study by Klomek et al of 5302 children in Finland born in 1981, the authors found evidence of bullying at age 8 years was linked to self-destructive behavior later in life.^[39] When controlling for depression and conduct symptoms, suicide attempts and completions in later life in females were significantly correlated to bullying. However, the same correlation was not apparent for males.^[39]

Economic instability and status

Times of economic change, especially economic depressions, have also been associated with suicides. The start of the Great Depression in the United States was accompanied by a number of suicides. Emile Durkheim noted that in times of major societal alternations, when the rules are in flux and people do not know what is expected of them, the self-destructive rate increases. He termed this period of cultural changes anomie.

Poverty and low income, with concomitantly fewer options and opportunities, also correlate with suicide.^[10]

Media and the Internet

Media can be a suicidal factor in negative and positive ways.

The Internet, and other media, can provide information concerning "how-to" methods. A 2008 study found many Websites providing specific techniques on suicide.^[40] That same study also found many antisuicide sites and a surprising number of prosuicide sites.

Books can also have a negative impact on suicide. A patient, after reading the book Final Exit, used one of the methods described to complete a suicide. Furthermore, antipsychiatric Internet sites are available that decry mental health explanations and, for example, show ways to be more effective at being anorexic. The Internet has also been used to broadcast suicides and has been a tool used to develop suicide pacts.^[41]

However, a number of Web sites do provide encouragement for treatments, accounts of successful interventions, and key resources.^[42] In addition, individuals have used the Internet to take online questionnaires that can indicate depression and suicide potential; as a result of taking these surveys, some college students sought treatment.^[43]

Psychodynamic formulation

Several individual psychodynamic ways of viewing suicide exist. In one situation, patients deflect anger inward to hurt themselves when they want to strike out at others. For example, a young man grounded by his parents for misbehavior takes an overdose to punish them.

Alternately, the psychoanalytic notion of incorporation and killing the interject exists. In this situation, patients have unconsciously incorporated an ambivalently held object (eg, a family member). For example, a man incorporates his father. He then attacks the interject (father) by killing himself.

Impulsivity

In many cases, suicidal behavior results from a person acting impulsively. Burton and colleagues have shown that a lack of executive functioning in the form of poor impulse control inhibition represents a suicide risk. Impulsivity can often separate people who just have suicide ideation from those who actually attempt suicide.^[44] However, Spokas et al suggest that impulsive attempts have valid significance and are similar in risk of completed suicide compared with premeditated attempts.^[45] Hence, an assessment of the patient’s impulse control is critical.

Other risk factors

A number of other factors are closely linked to suicide, including marital status, altitude, perceived/actual incarceration, lack of impulse control, and lack of daylight exposure.

People who are married are less suicidal than those who are single, divorced, or widowed. Isolated individuals are at greater risk than those involved with others and their community.

A study by Kim et al described altitude as a risk factor for suicide.^[46] Their study concluded that when gun ownership, altitude, and population density are considered as predictor variables for suicide rates on a state-by-state basis, altitude is a significant independent risk factor. Thus, the higher the altitude, the higher the risk of suicide.^[46] This association may be related to metabolic stress associated with mild hypoxia in individuals with mood disorders.

If an individual feels or is indeed trapped, especially those who are incarcerated, they are at suicide risk. Prisoners have a high rate of suicide; this is common during the first hours to week of being placed in confinement.^{[47, 48]} The first week after a patient's discharge from a psychiatric hospital or unit is of particularly high risk for a suicide.^[49] For many, the transition is difficult, challenging, and anxiety provoking.

The risk of suicide should be extended to all persons involved with the criminal justice system. Webb et al determined that major health and social problems frequently coexist in this population, including offending, psychopathology, and suicidal behavior.^[50] Further prevention strategies are needed for this group, including improved mental health service provision for all people in the criminal justice system, even those found not guilty and those not given custodial services. Better coordination is needed in public services to tackle coexisting health and social problems.

Lack of daylight correlates with depression and suicide. Regions with long, dark winters have high suicide rates, such as Scandinavia and parts of Alaska (eg, Nome). Indeed, persons with seasonal affective disorders (SAD) who live in these regions experience depression in the absence of sunlight and, hence, have a higher susceptibility to depression, which may lead to suicide.

In many cases, suicidal behavior results from a person acting impulsively. Burton and colleagues showed that a lack of executive functioning in the form of poor impulse control inhibition represents a suicide risk. Impulsivity can often separates people who just have suicidal ideation from those who actually attempt suicide.^[51] Hence, an assessment of a patient's impulse control is critical.

There has long been noted a correlation between low levels of total serum cholesterol and suicidal activity. Olié and associates found lower cholesterol levels in persons who attempted suicide, suggesting serum cholesterol levels could possibly be used as a biological marker for potential suicide risk.^[52]

Sleep difficulty remains an indicator for not only depression and anxiety disorders but also a risk factor for suicide. Bjørngaard and colleagues studied sleeping problems and suicide in 75,000 Norwegian adults for 20 years. They concluded problems with sleeping, perhaps in combination with or as a consequence of anxiety and depression, should be considered a marker of suicide risk^[53]

Although more studies are needed, a study by Lewis et al suggested that low serum docosahexaenoic acid (DHA) levels may be a risk factor for suicide. The authors studied active-duty US military personnel and found that the risk of suicide death was 14% higher per standard deviation of lower DHA percentage; among men, the risk of suicide death was 62% greater with low serum DHA status.^[54]

Other demographic factors are associated with suicide. These are discussed in Epidemiology.

Suicide represents the 11th leading cause of death in the United States and the 3rd leading cause of death for children, adolescents, and young adults. In 2007, 34,598 suicidal deaths occurred.^[2] Although demographics are discussed individually, several demographic factors often occur in the same person. For example, a police officer with major depression and a significant problem with alcohol commits suicide using his service revolver. (Unfortunately, this happens not infrequently.) This self-destructive event involves 5 risk factors—sex, occupation, depression, alcohol, and gun availability.

United States and international data

In the United States, certain states have higher suicide rates than others, as illustrated by the image below. Examining the nation regionally, the Western states have the highest suicide rates, with the exception of Vermont. In addition, living in rural areas carries a higher risk of suicide than living in urban areas.^[55]

The image below depicts suicide rates in the United States by region, 2000-2006.

Globally, a remarkable range in suicide rates exists. The highest rates for men are in Hungary and Finland. The United States is in the middle, and the lowest rates are in Greece, followed by Mexico and the Netherlands. Moreover, in certain cultures, suicide is considered more acceptable than in others. For example, the Japanese culture often regarded suicide as an honorable solution to certain situations.

Remarkably, although suicide remains a major cause of death internationally, treatment of suicidal people around the world is quite lacking. Bruffaerts and colleagues used World Health Organization (WHO) data to conclude that most people with suicidal ideation, suicide plans, and suicide attempts do not receive treatment. This finding extended across various different areas around the world, especially in low-income countries.^[56]

Religion may also play a role in suicide. Historically in the United States, Protestants have a higher rate of suicide than either Catholics or Jews. Some religions may encourage suicide in situations of disgrace or for patriotic reasons.

Racial differences in suicide

In the United States, most suicides occur within the white population. In men, the rate for white men in 2007 was 13.5 cases per 100,000 population; for black men, 5.1 cases per 100,000 population; and for Hispanic men, 6.0 cases per 100,000 population.^[1] However, the rate for Native American and Alaska Native men was 14.3 cases per 100,000 population.^[1] Furthermore, in sampling surveys (one from 53 countries and one from 43 countries), Voracek et al found that regardless of sex or age, people with a lighter skin color have a higher rate of suicide than those with darker skin color.^[57]

Sexual differences in suicide

The sex of the person who attempts or commits suicide represents one of the most salient and enduring features in self-destructive statistics. Men commit suicide far more frequently than women. In the United States, the difference is quite striking. Suicide was the 7th leading cause of death for males and the 15th leading cause of death for females in 2007.^[1] However, women make far more attempts than men, at a rate of 2-3 times more attempts than men.^[58] Furthermore, the sex differential continues in those who are suicidal who seek help. Namely, females are much more prone to go for medical and psychiatric aid then men are.^[59]

Although the facts allow many interpretations, such as method (men use firearms, and women use poison) and ability to handle feelings, the fact remains that difference in frequency related to sex is a powerful and relatively consistent finding across a wide range of other demographic categories, such as age, socioeconomic factors, and region.

Age-related differences in suicide

In general, the suicide rate increases with age, with a major significant spike in adolescents and young adults. In recent decades, the number of adolescent suicides has increased dramatically. The 2007 Youth Risk Behavior Surveillance showed that 6.9% of high school students had attempted suicide in the year before the survey.^[60]

With increasing age, a critical relationship emerges with suicide. Geriatric suicide is extremely prevalent. People older than 75 years have the highest rate of suicide. In 2007, the incidence of suicide in those aged 75 years and older was 36.1 for every 100,000 people, compared with the national average of 11.26 suicides for every 100,000 people.^[1] That age group also maintains an alarming connection with murder-suicides.^[61]

Note the image below for sex, race, and age.

Occupation-related differences in suicide

Police or public safety officers are at risk for suicide. The long hours of work, the scenes they witness daily, the availability of guns, and the silence encouraged by the profession (keeping within the "wall-of-blue"), as well as alcohol usage and divorces contribute to this risk.

Physicians, especially those who deal with progressively terminally ill patients, as well as dentists, also have a high rate of suicide. In the United States, the medical field loses the equivalent of a medical school class each year by suicide. Perhaps, elements of obsessive and perfectionist tendencies combined with personal feelings of isolation may contribute to this high number of self-induced deaths.

See Physician Suicide.

Suicide risk in military personnel has been increasing, as shown in the figure below.

Seasonal variances in suicide

Most suicides occur in the spring; the month of May particularly has been noted for its high rate of suicide. The speculation is that during the winter and early spring when people are depressed, they are often surrounded by others who are feeling downhearted because of the weather. However, with the arrival of the spring season and the month of May, people who are depressed because of the weather are cheered and people who are depressed for other reasons remain depressed. As others cheer up, those who remain miserable must confront their own unhappiness.

It is critical for patients to appreciate that their suicidal behavior reflects their mental illnesses. Suicidal behavior is a manifestation of depression or a result of alcohol or other substances. The first intervention must be to prevent the suicide or to sustain life. Then, treat the underlying problem and mental disorder.

The patient's family needs to see the self-behavior as a sign of a deeper problem. Family members often struggle with a series of often conflicting feelings about the suicidal activities. Education and an opportunity to discuss their feelings can help.

Helpful Web sites for patients include the following:

• American Association of Suicidology
• NIMH - Suicide Prevention
• NIMH - Suicide Warning Signs
• US Centers for Disease Control and Prevention (CDC) Suicide Prevention

For patient education information, see Depression Center, as well as Depression and Suicidal Thoughts.