Understanding Suicide: Causes and Prevention Strategies

1. Chapter Eight Suicide

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.)

18. 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

19. Suicide and Specific Populations • Three groups of people affected by suicide: • Children and adolescents • College students • Elderly people

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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.

33. 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

34. 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

35. 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)

36. 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)

37. 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

38. 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