Suicide is a health, family, institutional, political, and social issue of tremendous significance, and the field of suicide prevention is a significant priority for both public and mental health. Federal initiatives, consumer advocacy, clinical efforts, and empirical work have significantly advanced the field. While great strides have been made in the area of suicide prevention over the past two decades, the morbidity and mortality related to suicide remains significant. The short- and long-term impact of the death of one person by suicide is far reaching.
Epidemiology: Suicide Morbidity and Mortality
Suicide rates can be examined from many perspectives—internationally, nationally, regionally, temporally, racially, by gender or age cohorts. More than 30,000 suicides occur every year in the United States and more than 80 suicides each day, or approximately 1 suicide every 16.7 minutes. In 2004, suicide was the 11th leading cause of death, while homicide was 15th. The rates are highest in persons over 80, and suicide is the third leading cause of death for youth ages 15-25 years. The rates are increasing for youth ages 10-14 years. Males and Caucasians are more likely to die by suicide than are females and other races. Firearms are the major method (50 percent) for completed suicide (hanging is second). In fact, each year there are more firearm suicides than firearm homicides. And sadly, U.S. soldiers involved in the Iraqi Freedom conflict are dying by suicide in increasing numbers, beyond average rates for military persons.
The Surgeon General’s Report on ethnicity, race, and mental health underscored the significance of suicide in the major racial and ethnicity groups, including Asian, black, Caucasian, and Hispanic persons. The suicide rate for Native Americans is the highest next to whites, and suicide was the second leading cause of death for American Indians/Alaskan Natives in 1999-2004. Suicide is the eighth leading cause of death for Asian Americans/Pacific Islanders, in particular the elderly. The highest rates for blacks are among young males ages 20-24.
Somewhere between 8 and 25 suicide attempts occur for every death by suicide. The ratio of attempts to suicide deaths in adolescents is approximately 1 to 100-200. Females have the highest rate of suicide attempts, and the ratio of attempts by females versus males is 3:1. Approximately 650,000 persons receive treatment following an attempt each year. The most common method for attempts is overdose. The rates of attempts increase in the elderly. The risk for attempting suicide in blacks is highest among 15- to 24-year-olds. The Centers for Disease Control and Prevention 2005 Youth Risk Behavior Surveillance System surveyed high school students and determined the rates of suicidal behavior were highest in Hispanic youth, particularly Hispanic females.
Risk and Protective Factors Framework
The risk and protective factors framework helps explain, assess, and intervene with suicidal behavior. Risk or protective factors are characteristics or conditions that, when present, increase or decrease respectively the likelihood that persons will develop suicidal behavior. Risk and protective factors include individual, familial, psychological, or environmental domains.
Examples of common suicide risk factors include the following: individual factors, such as gender, genetic vulnerability, chronic physical illness, and poor coping skills; family factors, such as severe marital discord, psychiatric disorders, suicide of a family member, and abuse and neglect; psychiatric factors, such as depression, substance use or abuse, and limited access to mental health services; and environmental factors, such as violence, poverty, racism, lack of social support, and access to highly lethal means of suicide. Protective factors include resilience, family ties, cultural and religious beliefs that discourage suicide and support self-preservation, culturally sensitive programs that strengthen family ties, tribal spiritual orientation, and specialized mental health and addictions treatment.
The majority (90 percent) of persons who die by suicide have a psychiatric illness (most often depression); however, one particular risk factor increases the probability but is not necessarily the cause of suicidal behavior. It is the accumulation and interaction of risk and protective factors that contribute to mental health problems (like suicide) or illness and mental health, rather than a single risk or protective factor. Resilience, or the capacity to bounce back from adversity, has received considerable attention in mental health promotion. Resilience stems from the interaction of an individual situation with protective factors from the environment. In the clinical application of the risk and protective factors model, the modifiability of a risk or protective factor is a prerequisite for the development of interventions targeting such factors.
Nomenclature for Self-Injurious Thoughts and Behaviors
There is much confusion and misuse of words related to suicidology. A newly revised nomenclature seeks to increase the ability of clinicians, epidemiologists, policymakers, and researchers to communicate more clearly and study similar types of suicidal behavior. The essential components of this nomenclature include suicide-related communications, suicide-related behavior, and suicide-related ideations. Suicide-related communications is defined in this nomenclature as any interpersonal act of imparting, conveying, or transmitting suicidal thoughts, wishes, desires, or intent (explicit or implicit), including threats or plans. Suicide-related behavior is a self-inflicted, potentially injurious behavior for which there is evidence that the person wished to use the appearance of intending to kill himself or herself in order to attain some other end or the person intended at some undetermined or some known degree to kill himself or herself. These behaviors include self-harm, self-inflicted unintentional death, undetermined suicide-related behaviors, self-inflicted death with undetermined intent, suicide attempt, and suicide. A suicide attempt is self-inflicted, potentially injurious behavior with a nonfatal outcome for which there is evidence (explicit or implicit) of intent to die. A suicide attempt may result in no injury, injuries, or in death, defined as suicide.
Suicidology refers broadly to the study, prevention, and intervention of suicide. Suicide assessment measures include screening tools, risk assessment instruments, and assessment of clinical characteristics of suicidal persons. Reviews of suicide assessment tools for adults and youth are available from the National Institute of Mental Health. No single best instrument yet exists; the gold standard for assessment is the clinical interview.
The American Psychiatric Association recommends the following components of suicide assessment: identify specific psychiatric signs and symptoms; assess past suicidal behaviors, including intent of self-injurious acts; review past treatment history and treatment relationships; identify family history of suicide, mental illness, and dysfunction; appreciate psychological strengths and vulnerabilities of the individual patient; and specifically inquire about suicidal thoughts, plans, and behaviors (suicidal ideation, suicide plan, suicidal intent, lethality of plan, and means). Recently an American Association of Suicidology study of imminent (current or immediate) risk for suicide revealed empirical evidence for the following warning signs: ideation, substance abuse, purpose, anxiety, a feeling of being trapped, withdrawal, anger, recklessness, and mood changes. The acronym for these warning signs is IS PATH WARM. Clinical researchers also developed various structures for suicide risk assessment and intervention and underscored the need for systematic and repeated assessments. Risk level is typically rated as mild or nonexistent, moderate, or severe, with interventions based on the severity of risk. Moderate or severe risk is considered a psychiatric emergency.
An Institute of Medicine report on reducing suicide summarized many evidential aspects of clinical interventions, including psychoactive medications, electroconvulsive therapy, psychotherapies, inpatient care, after-discharge risk, treatment adherence, and follow-up care. Suicide risk is the most common precipitant for hospitalization. The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) has also acknowledged that suicide is the most frequent sentinel event in health care facilities, as approximately 5-6 percent of suicides occur during hospitalization. About 1,500 inpatient suicides occur each year, most often during the first week of hospitalization. As a result, the 2007 National Patient Safety Goals for Hospitals and Behavioral Health include the safety of persons at risk for suicide. Furthermore, the American Association for Suicidology published “Recommendations for Inpatient and Residential Patients Known to Be at Elevated Risk for Suicide,” while forensic experts in suicidology have proposed clinical and legal standards of care for suicide prevention.
Research in Suicidology
Following the 1992 recommendation of the Centers for Disease Control and Prevention for strategies for youth suicide prevention, a strong push followed for evidence-based practice in suicide prevention. A series of reviews of youth programs, primarily by Canadian groups, focused mostly on school-based programs. One such review emphasized the effectiveness of cognitive-behavioral therapy (CBT) for suicide prevention, most particularly CBT with a problem-solving component. A significant increase in biological research took place, such as postmortem brain autopsies of persons who die by suicide. Only two psychopharmacological agents, Lithium and Clozaril, have thus far demonstrated a direct reduction of suicide symptoms. However, research does show that increased suicide risk relates both to failure to medicate certain psychiatric illnesses and to client adherence issues.
One of the leading science reports in suicidology is the Institute of Medicine report on reducing suicide. Another resource is the Best Practices Registry (BPR) for suicide prevention, a collaboration between the Suicide Prevention Resource Center (SPRC) and the American Foundation for Suicide Prevention (AFSP), funded by the Substance Abuse and Mental Health Services Administration (SAMHSA).The purpose of the BPR is to identify, review, and disseminate information about best practices that address specific objectives of the National Strategy for Suicide Prevention.
The National Institute of Mental Health has a Suicide Prevention Consortium that oversees the suicide research portfolio, including studies that underscore such findings as 70 percent of elderly suicides saw a primary care provider in the month before they died. Other significant studies have included a surveillance study of adolescent attempters seen in emergency departments in Oregon, psychological autopsy studies of teen suicide, and the community evaluation of the Air Force plan. Several journals are also devoted to suicidology.
Policy and Suicidology
In the early 1990s, a shift to the public health for suicide prevention from the mental health approach occurred, sparked by the 1984 Task Force on Youth Suicide. A series of national meetings and policy reports reflected this shift in attitudes, science, and funding priorities. Then, in 1999, Surgeon General David Satcher issued the Call to Action to Prevent Suicide, a blueprint for addressing suicide that succeeded through awareness, intervention, and methodology based on the recommendations of the national Reno Conference that same year. After public hearings, a federal steering group drafted the National Strategy for Suicide Prevention.
The national strategy now informs funding priorities, research, and state and local plans. Every state has a suicide prevention task force, developed by regional health departments to implement the national strategy. Most states have a suicide prevention plan that may or may not have funding appropriated for the activities in the respective plans.
Society and Suicidology
The Suicide Prevention Resource Center has outlined the history of suicide prevention. Significant events included the Los Angeles Suicide Prevention Center, opened in 1958 and funded by the U.S. Public Health Service. Edwin Shneidman was the director of that center and is often referred to as the “father of suicidology.” His prominence rests on numerous contributions to the field, particularly his elucidation of the phenomenon of psychache, the unbearable pain experienced by suicidal persons.
The consumer movement in suicide prevention has had a major influence on shifting the federal priorities. Perhaps the consumer exemplar is the Suicide Prevention Action Network (SPAN USA), founded in 1996 in Marietta, Georgia, by Jerry and Elsie Weyrauch (parent survivors) with the goal of preventing suicide through public education, community action, and advocacy. Survivors are family members, significant others, or acquaintances who have experienced the loss of a loved one as the result of suicide. The Weyrauchs and SPAN USA efforts have had a dramatic impact on policy advances, such as the passage of Senate Resolution #84 and House Resolution # 212 for suicide prevention during the 105th Congress. Public acknowledgment by well-known persons of either their own suicide experience or survivorship has also done much to increase awareness and decrease stigma.
Another significant part of societal impact is education. Several professional organizations focus on suicide prevention. The primary organizations in suicidology are the American Association of Suicidology (AAS), American Foundation for Suicide Prevention (AFSP), the International Association of Suicide Prevention (IASP), and the Suicide Prevention Resource Center (SPRC). An exemplar in training is the SPRC and AAS training, “Assessing and Managing Suicide Risk.” This competency-based training has been delivered to mental health professionals across the nation.
With increased suicide rates among minority groups, cultural competency has become a vital design and implementation criterion for suicide prevention activities. Suicidal youth or those at risk for suicide often require emergency room treatment. An ideal program demonstrating cultural competence is the emergency department adherence program for Hispanic adolescents. Included on the SPRC Best Practice Registry, it incorporates an orientation video for families, an on-call bilingual crisis therapist or crisis manager, and an interdisciplinary training program for emergency department personnel.
Another cultural adaptation demonstrated that when staff in a rural emergency department provided education in means restriction (decreasing access to lethal means of suicide) for parents of youth at risk for suicide, parents were more likely to lock up medications and firearms.
A famous pioneer in suicide prevention, Robert Litman, warned those in suicidology that the field is risky and dangerous and one must anticipate casualties. Although we will never be able to save every person from suicide, if consumers, professionals, researchers, and policymakers continue to build partnerships, we can make a difference, one life at a time. Every life saved is significant.
- American Academy of Child and Adolescent Psychiatry. 2001. “Practice Parameters for Assessment and Treatment of Children and Adolescents with Suicidal Behaviors.” Journal of Academy and Child and Adolescent Psychiatry 40:24S-51S.
- American Association of Suicidology. (http://www.suicidology.org/).
- American Foundation for Suicide Prevention. (https://afsp.org/).
- Bongar, Bruce. 2002. The Suicidal Patient: Clinical and Legal Standards of Care. 2nd ed. Washington, DC: American Psychological Press.
- Centers for Disease Control and Prevention. 1992. “Youth Suicide Prevention Programs: A Resource Guide.” Atlanta, GA: National Center for Injury Prevention and Control.
- Goldmith, S. K., T. C. Pellmar, A. M. Klemman, and W. E. Bunney, eds. 2002. Reducing Suicide: A National Imperative. Washington, DC: National Academies Press.
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- National Institute of Mental Health. (https://www.nimh.nih.gov/index.shtml).
- Rudd, M. David, Thomas E. Joiner, and M. Hassan Rajab 2001. Treating Suicidal Behavior: An Effective Time-Limited Approach. New York: Guildford.
- Silverman, Morton M., Alan L. Berman, Nels D. Sanddal, Patrick W. O’Carroll, and Thomas E. Joiner. 2007. “Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 2: Suicide-Related Ideations, Communications, and Behaviors.” Suicide and Life-Threatening Behavior 30:264-77.
- S. Department of Health and Human Services. 2001. Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General.
- S. Department of Health and Human Services. “National Strategy for Suicide Prevention: Goals and Objectives for Action.” Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Retrieved March 27, 2017 (https://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/).
- Work Group on Suicidal Behaviors Practice. 2003. “Guidelines for the Assessment and Treatment of Patients with Suicidal Behavior.” American Journal of Psychiatry 160(suppl):11.
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