Section 7. Mental Health Disorders

Chapter 102. Suicidal Behavior

Topic: Suicidal Behavior

Suicidal Behavior

Suicidal behavior is characterized by a successful or unsuccessful attempt to kill oneself.

Suicidal behavior is an unmistakable signal that a person has feelings of desperation and hopelessness. Suicidal behavior includes attempted suicide, suicide gestures, and completed suicide. An attempted suicide is a suicidal action that is not fatal. If an attempted suicide involves a suicidal action unlikely to have any potential of being fatal, it is called a suicide gesture. A person taking such an action (for example, ingesting six acetaminophen tablets) may be making a plea for help or attention without having any intention of actually ending his life. A completed suicide is a suicidal action that results in death.

Information on the frequency of suicide comes mainly from death certificates and inquest reports and probably underestimates the true rate. Even so, suicidal behavior clearly is an all-too-common health problem. Although most suicidal behavior does not result in death, 10% of people who try to kill themselves using a potentially fatal means do die from their actions.

Suicidal behavior occurs in people of all ages and of both sexes. Suicide is the second leading cause of death among adolescents and is one of the top 10 causes of death among adults in the United States. The highest rate of completed suicide is among men older than 70. In contrast, suicide attempts are more common before middle age. Attempted suicide is particularly common among adolescent girls and single men in their 30s. Across all age groups, women attempt suicide 2 to 3 times more often than men, but men are more apt to die in their attempts.

Married people of either sex, particularly those in a secure relationship, have a much lower suicide rate than single people. People who live alone because of separation, divorce, or a spouse's death have higher rates of attempted and completed suicides. Having a family member who has attempted suicide may increase the risk as well.

Suicide among black women has increased 80% in the last 20 years, so that the overall rate for blacks now equals that for whites, especially in urban areas. Among Native Americans, the rate has also risen recently; in some tribes, it is 5 times the national average. Suicide rates are higher in urban areas than in rural areas worldwide. Many suicides take place in prisons.

Practicing members of most religious groups (particularly Roman Catholics and Jews) are less likely to commit suicide. Such people are generally supported by their beliefs and are provided with close social bonds protecting against acts of self-destruction. However, religious affiliation and strong religious beliefs do not necessarily prevent individual impetuous, unpremeditated suicidal acts during times of frustration, anger, and despair, especially when accompanied by delusions of guilt and unworthiness.

Suicide notes are left by about one of four people who complete suicide. The notes often refer to personal relationships and events that will follow the person's death. Notes left by older people often express concern for those left behind, whereas those of younger people may express anger or vindictiveness. The content of the note may indicate that the person had a mental health disorder that led to the suicidal act.

See the sidebar High-Risk Factors for Suicide.

Causes

Suicidal behaviors usually result from the interaction of several factors, the most common of which is depression (see Section 7, Chapter 101). In fact, depression is involved in over 50% of attempted suicides. Marital problems, unhappy or ended love affairs, disputes with parents (among adolescents), or the recent loss of a loved one (particularly among older people) may precipitate the depression. Often, one factor, such as a disruption of an important relationship, is the last straw.

Depression associated with a medical disorder may lead to a suicide attempt. Most medical disorders associated with increased suicide rates either directly affect the nervous system and brain (such as AIDS, dementia, or temporal lobe epilepsy) or involve treatments that can cause depression (such as certain drugs used to treat high blood pressure). People whose depression includes anxiety or features of psychosis, such as false beliefs (delusions), may be at higher risk of suicide than those whose depression does not include these features.

People who have had traumatic childhood experiences, particularly the distresses of a broken home, parental deprivation, or abuse, are more likely to attempt suicide, perhaps because they are at higher risk of becoming depressed. Attempted suicide is also more likely among battered wives, many of whom were abused as children.

Depression may be intensified by the use of alcohol, which in turn makes suicidal behavior more likely. The use of alcohol diminishes self-control as well. About 30% of people who attempt suicide drink alcohol before the attempt. Because alcoholism, particularly binge drinking, often causes deep feelings of remorse during dry periods, alcoholics are suicide-prone even when sober.

In addition to depression, other mental health disorders put people at risk of suicide. People with schizophrenia (see Section 7, Chapter 107) and other psychotic disorders may hear voices (auditory hallucinations) commanding them to kill themselves. People with borderline personality disorder (see Section 7, Chapter 105) or antisocial personality disorder (see Section 7, Chapter 105), especially those with a history of violent behavior, may use suicide gestures or attempted suicide as a means of getting back at someone or of making a statement.

Methods

The choice of method often is influenced by cultural factors and availability and may or may not reflect the seriousness of intent. Some methods (for example, jumping from a tall building) make survival virtually impossible, whereas other methods (for example, overdosing on drugs) make rescue possible. However, even if a person uses a method that proves not to be fatal, the intent may have been just as serious as that of a person whose method was fatal.

Drug overdose and self-poisoning are two of the most common methods used in suicide attempts. Acetaminophen is now the most commonly used drug in attempted suicide, but antidepressants or a combination of drugs are also commonly used.

Violent methods, such as gunshots and hanging, are uncommon among attempted suicides because they usually result in death. Of completed suicides, a gunshot is the method most frequently used in the United States. It is a method predominantly used by males. Females are more likely to use nonviolent methods, such as poisoning, drug overdose, or drowning.

Prevention

Although some attempted or completed suicides come as a shock even to family and friends, clear warnings are given in most cases. Any suicide threat or suicide attempt is a plea for help and must be taken seriously. If the threat or attempt is ignored, a life may be lost.

If a person is threatening or has already attempted suicide, the police should be contacted immediately so that emergency services can arrive as soon as possible. Until help arrives, the person should be spoken to in a calm, supportive manner.

A doctor usually hospitalizes a person who has threatened or attempted suicide. Even if the person does not agree to hospitalization, most states allow a doctor to hospitalize a person against his wishes if the doctor believes that the person is at high risk of harming himself.

See the sidebar Suicide Intervention: Crisis Hot Lines.

Impact of Suicide

Any suicidal act has a marked emotional effect on all involved. The person's family, friends, and doctor may feel guilt, shame, and remorse at not having prevented the suicide. They may also feel anger toward the person. Eventually, they may realize that they could not have prevented the suicide. Sometimes a grief counselor or a self-help group, such as Survivors of Suicide, can help family and friends deal with their feelings of guilt and sorrow. The primary care doctor or local mental health services (for example, at the county or state level) can often help locate these resources. In addition, national organizations, such as the American Foundation for Suicide Prevention, often maintain directories of local support groups. Resources are available on the Internet as well.

The effect of attempted suicide is similar. However, family members and friends have the opportunity to resolve their feelings by responding appropriately to the person's cry for help.

Assisted Suicide

Assisted suicide refers to the help given to a person who wishes to end his life by a doctor or other health care professional or even by a family member or friend. Assisted suicide is very controversial because it reverses the doctor's usual goal, which is to preserve life. Assisted suicide is illegal in all states except Oregon. In the rest of the United States, doctors can provide treatment intended to minimize physical and emotional suffering, but they cannot specifically intend to hasten death.