Chapter Eight

Suicide

Suicide

• Suicide:– The intentional, direct, and conscious taking of

one’s own life– Not classified as a mental disorder, although the

suicidal person usually has psychiatric symptoms, such as:

• Depression, alcohol dependence, and schizophrenia

– Suicide and suicidal ideation (thoughts about suicide) may represent a separate clinical entity

Correlates of Suicide

• Psychological autopsy: – Systematic examination of existing information to

understand and explain a person’s behavior before death

– Suicide survivors are different from those who succeed:

• Typical attempter: White female housewife in 20s-30s with marital difficulties; uses barbiturates

• Typical succeeder: Male in 40s or older with poor health or depression; uses gun or hangs himself

Facts About Suicide

• Frequency:– Approximately 34,000 people commit suicide each

year– Among top 11 causes of death in industrialized

parts of the world– Number of actual suicides is probably 25-30%

higher than what is recorded

Facts About Suicide (cont’d.)

• Suicide publicity/identification with victims:– Media reports of suicide, especially celebrity

suicide, spark increase in suicide– Suicides by young people in small communities

evoke copycat suicides

• Gender:– Men are about four times as likely to be successful

(they use more lethal means)– Women are more likely to attempt suicide

Facts About Suicide (cont’d.)

• Marital status:– Married people are less vulnerable– Divorced and widowed individuals are more

vulnerable

• Occupation: – Higher risk for physicians, lawyers, law

enforcement personnel, and dentists– Burnout, stress, and guilt over medical errors may

increase risk for surgeons

Facts About Suicide (cont’d.)

• Socioeconomic level is not a factor• Choice of method:

– Over 50% of suicides are committed using firearms

– 70% of attempts are from drug overdose– Most common means for children under 15 is

jumping from buildings and running into traffic– Most common means for adolescents over 15 is

drug overdose or hanging themselves

Facts About Suicide (cont’d.)

• Religious affiliation:– Correlated with suicide rates– Suicide rates are lower in Catholic and Muslim

countries where there is strong condemnation of suicide

– Where religious sanctions are weaker—e.g., Scandinavian countries, former Czechoslovakia, Hungary—suicide rate is higher

Facts About Suicide (cont’d.)

• Ethnic and cultural variables:– Highest rates in U.S. are for American Indian;

lowest for Asian Americans– High rates of alcoholism, low standard of living,

and invalidation of cultural lifestyles also contributing factors

Facts About Suicide (cont’d.)

• Historical period:– Tends to decline during times of war and natural

disasters– Increase during periods of shifting norms and

values or social unrest

• Communication of intent:– More than two-thirds of those who commit

suicide communicate their intent to do so within three months of the act

Facts About Suicide (cont’d.)

• Reinforcing protective factors:– Reawakening and reinforcing desire to live– Expanding perceptual outlook by reducing suicide

myopia– Enhancing social connectedness– Increasing repertoire of coping skills

A Multipath Perspective of Suicide

• Most viable explanation of mental disorders must come from an integrated and multidimensional analysis

• Many different factors involved in suicide– Biological– Psychological– Social– Sociocultural

Biological Dimension

• Suicide influenced by low serotonin levels in the brain– 5-hydroxyindoleacetic acid (5HIAA):

• Produced when serotonin is broken down in the body• Low amounts of 5-HIAA in suicidal patients

• Genetics: – High rate of suicide and suicide attempts among

parents and close relatives of individuals who attempt or complete suicide

– Unclear relationship

Psychological Dimension

• Depression and hopelessness:– Depression plays important role; relationship is

complex– Increase in sadness is a frequent mood indicator

of suicide– Heightened feelings of anxiety, anger, and shame

also associated– Hopelessness, or negative expectations about

future, may be even stronger factor

Psychological Dimension (cont’d.)

• Alcohol consumption:– One of most consistent correlates

• As many as 70% of suicide attempts involve alcohol

– Also strong correlation to successful attempt– May lower inhibitions related to fear of death – Alcohol-induced myopia: a constriction of

cognitive and perceptual processes– May increase distress by focusing thoughts on the

negative aspects of their personal situations

Social Dimension

• Many suicides are interpersonal in nature and are influenced by relationships involving a significant other

• Individuals who are incapacitated or have a terminal illness are often at higher risk

• Family instability, stress, and chaotic family atmosphere related to attempts by younger children

Social Dimension (cont’d.)

• Interpersonal-psychological theory of suicide (Joiner):– Perceived burdensomeness– Thwarted belongingness– Acquired capacity for suicide

• Social factors that separate people or make them less connected to other things they care about (e.g., family religious affiliation, etc.)

Sociocultural Dimension

• Emile Durkheim: – Inability to integrate oneself into society; lack of

close ties deprives one of support systems necessary for adaptive functioning

• Other factors:– Modern mobile society that de-emphasizes

importance of family and sense of community– Further group goals or achieve greater good– Social change and disorganization within one’s

community

Suicide and Specific Populations

• Three groups of people affected by suicide:– Children and adolescents– College students– Elderly people

Suicide Among Children and Adolescents

• Suicide rate for children under 14 is increasing at alarming rate

• Suicide is third leading cause of death among teenagers

• Teen suicide increased by 18% in 2004 and by 17% in 2005

• High school study: 13.8% considered suicide, 6.3% attempted, and 1.9% required medical attention

Suicide Among Children and Adolescents (cont’d.)

• The role of bullying:– “Bullycide”: bullying leading to suicide– Bullying victims are 2-9 times more likely to

consider suicide than non victims– Nearly 50% of young people who commit suicide

experienced bullying

• Copycat suicides: – Youngsters mimic a previous suicide– Highly publicized suicides increase the number of

attempts

Suicide Among Children and Adolescents (cont’d.)

• Decrease in antidepressant medication:– 2004 FDA warning of an increased suicide risk for

children taking SSRI antidepressants– Recent research suggests SSRIs may increase

suicidal thoughts or behaviors for very select few– Increase in youth suicide rates since FDA warning

because antidepressants are less likely to be prescribed

Suicide Among College Students

• According to study, suicide rates among college students are no higher than noncollege group but:– Limited access to lethal means– Decreasing proportion of males attending college– Nearly 1,000 students commit suicide per year– 44% increase in students with psychiatric

disorders– Between 2009 and 2010 serious thoughts of

suicide among college students rose significantly

Suicide Among College Students (cont’d.)

• College study:– More than 50% reported suicidal thoughts– 14% of undergraduates and 8% of graduates had

made a suicide attempt

• Development of programs and resources to:– Identify warning signs– Have well-established suicide prevention

procedures – Clearly identify resources for a suicidal crisis

Suicide Among the Elderly

• Unwelcome physical changes, including wrinkling, graying hair, and diminished physical strength

• Life events connected with “feeling old” lead to depression (one of the most common psychiatric complaints of the elderly)

• Suicide rates for elderly white men are the highest for any age group

Suicide Among the Elderly (cont’d.)

• Firearms are most common method for people over 65 years old

• Elderly make fewer attempts per completed suicide

• For Asian Americans, the highest risk is for first-generation immigrants

• Lowest rates among American Indians and African Americans

Preventing Suicide

• Assumption that potential victims are ambivalent: they have a strong wish to die, but also a wish to live

• Part of success in prevention is ability to assess lethality: – The probability that a person will choose to end

his or her life

Preventing Suicide (cont’d.)

• Three-step process for working with a potentially suicidal person:– Knowing which factors are highly correlated with

suicide– Determining probability that person will act on

suicide wish (high, moderate, or low)– Implementing appropriate actions

• Attempt to quantify the seriousness of each factor

Clues to Suicidal Intent

• Demographic: – Male, increased age, and history of suicide threat

• Specific:– Amount of detail in the threat– Direct access to means of suicide– Precipitating events– Verbal communication of intent (often this is

subtle)– “Practice run” at an actual attempt

Clues to Suicidal Intent (cont’d.)

• Indirect behavioral cues: – Puts affairs in order; takes a long trip; gives away

prized possessions; etc.

• Early signs: – Depression, guilt feelings, insomnia, tension,

nervousness, loss of weight, and impulsiveness

• Critical signs: – Sudden changes in behavior; gives away

possessions; threats or actual attempts

Clues to Suicidal Intent (cont’d.)

• Crisis intervention:– Clinical level:

• Educate staff at mental health institutions and schools to recognize signs of potential suicide

– Crisis intervention aimed at providing intensive short-term help to resolve immediate life crisis

• Patient may be immediately hospitalized, given medical treatment, seen by psychiatric team for two-four hours per day until stabilized

• Working with patient and taking charge of person’s personal, social, and professional life outside facility

Clues to Suicidal Intent (cont’d.)

Figure 8-2 The Process of Preventing Suicide Suicide prevention involves the careful assessment of risk factors to determine lethality- the probability that a person will choose to end his or her life. Working with an individual who is potentially is a three-step process that involves (1) knowing what factors are highly correlated with suicide; (2) determining whether there is high, moderate, or low probability that the person will act on the with;

and (3) implementing appropriate actions.

Clues to Suicidal Intent (cont’d.)

• After clients return to more stable emotional state and immediate risk has passed:– Traditional forms of treatment, inpatient or

outpatient, are used– Relatives and friends may be enlisted to help

monitor individual

Suicide Prevention Centers

• Many in acute distress are not being treated and may be unaware of available services

• Telephone crisis intervention:– Maintain contact and establish relationship– Obtain necessary information– Evaluate suicidal potential– Clarify nature of stress and focal problem– Assess strengths and resources– Recommend and initiate action plan

Suicide Prevention Centers(cont’d.)

• Today, there are about 200 suicide prevention centers in U.S., along with many suicide hotlines

• Little research has been done on effectiveness (anonymity)

The Right to Suicide

• A majority of Americans believe terminally ill individuals should be allowed to take their own lives

• Suicide is both a sin and an illegal act in most countries

• Oregon (1998): – Physician-assisted suicide act– U.S. Attorney General Ashcroft attempted to

overturn (U.S. Court of Appeals upheld Oregon’s law)

Moral, Ethical, and Legal Implications

• Recent legislation and literature has debated whether it is morally, ethically, and legally permissible to aid in suicide– Derek Humphrey’s Final Exit (1991):

• Hemlock Society’s manual on suicide– Doctor Jack Kevorkian:

• “Dr. Death” and his “suicide machine”

• Ironically, by prolonging life, medical science has also prolonged the process of dying

Moral, Ethical, and Legal Implications (cont’d.)

• Pro: – Suicide can be a rational act; mental health and

medical professionals should be allowed to help without fear or legal or professional repercussions

• Con: – Suicide is not rational, and it is dangerous to say

that it is• Criteria to decide between life and death:

– “Quality of life” and “quality of humanness” are subjective and difficult to define