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Suicidal Behavior

By Paula J. Clayton, MD, American Foundation for Suicide Prevention

Suicidal behavior includes completed suicide, and attempted suicide. Thoughts and plans about suicide are called suicide ideation.

  • Suicide usually results from the interaction of many factors, usually including depression.

  • Some methods, such as guns, are more likely to result in death, but choice of a less lethal method does not necessarily mean that the intent was less serious.

  • Any suicide threat or suicide attempt must be taken seriously, and help and support should be provided.

  • A telephone hot line is available for people who are considering suicide.

Suicidal behavior includes the following:

  • Completed suicide: An intentional act of self-harm that results in death.

  • Attempted suicide: An act of self-harm that is intended to result in death but does not. A suicide attempt may or may not result in injury.

Nonsuicidal self-injuryis an act of self-harm that is not intended to result in death. Such acts include inflicting scratches on the arms, burning oneself with a cigarette, and overdosing on vitamins. Nonsuicidal self-injury may be a way to reduce tension or may be a plea for help from people who still wish to live. These acts should not be dismissed lightly.

Information about the frequency of suicide comes mainly from death certificates and inquest reports and probably underestimates the true rate. Even so, suicidal behavior is an all-too-common health problem. Suicidal behavior occurs in people of all ages and of both sexes.

In the United States, in 2014 there were 42,773completed suicides. There is one death by suicide in the United States every 12.3 minutes. As a leading cause of death, suicide ranks as follows:

  • 3rd among young people aged 10 to 24

  • 2nd among people aged 25 to 34

  • 4th among those aged 35 to 64

  • 10th overall

The suicide rate is highest in people aged 45 to 64.

In all age groups, men who commit suicide outnumber women 4 to 1. The reasons are unclear, but the following may be involved:

  • When men have problems, they are less likely to seek help—from friends and/or health care practitioners.

  • Alcohol abuse and drug abuse, which appear to contribute to suicidal behavior, are more common among men.

  • Men are more aggressive and use more lethal means when they attempt suicide.

Each year, about 1 million people attempt suicide. The number of attempts is about 15 to 20 times higher than the number of completed suicides. Many people make repeated attempts. However, only 5 to 10% of people who make an attempt eventually die by suicide. Attempted suicide is particularly common among adolescent girls. Girls aged 15 to 19 attempt suicide 100 times more often than boys in the same age group. Across all age groups, women attempt suicide two or three times as often as men, but men are four times more likely to die in their attempts. Older people attempt suicide 4 times for every completed suicide.

Suicidal behavior in children and adolescents is discussed elsewhere (see Suicidal Behavior in Children and Adolescents).

People who have been separated, divorced, or widowed are more likely to complete suicide. Rates of attempted and completed suicide are higher among those who live alone. Having a family member who has attempted or completed suicide may increase the risk as well.

Whites are more likely to complete suicide than other ethnic groups. Black women attempt suicide nearly as often as white women but are less likely to die in their attempts.

Suicide is less common among people who are in a secure relationship than among single people and among practicing members of most religious groups. However, people of all races, creeds, incomes, and educational levels die by suicide. There is no typical suicide profile.

Did You Know?

  • Suicide is the 3rd leading cause of death among young people, but the rate of completed suicides is highest in people aged 45 to 64.

  • People who live alone are more likely to attempt or complete suicide.

Causes

About one in six people who kill themselves leaves a suicide note, which sometimes provides clues as to why.

Suicidal behaviors usually result from the interaction of several factors. The most common is

Depression is involved in over 50% of attempted suicides. Marital problems, recent arrest or trouble with the law, unhappy or ended love affairs, disputes with parents (among adolescents), or the recent loss of a loved one (particularly among older people) may trigger the depression. Often, one factor, such as a disruption of an important relationship, is the last straw in a series of upsetting circumstances. However, depression can occur "out of the blue" particularly if there is a family history of a mood disorder or suicide. The risk of suicide is higher if people with depression also have significant anxiety.

People with certain general medical disorders may become depressed and attempt or complete suicide. Most disorders associated with increased suicide rates either directly affect the nervous system and brain (such as AIDS, multiple sclerosis, or temporal lobe epilepsy) or involve treatments that can cause depression (such as certain drugs used to treat high blood pressure).

In older people, about 20% of suicides may at least partly be a response to serious chronic and painful physical disorders.

People who have traumatic childhood experiences, including abuse, are more likely to attempt suicide, perhaps because they are at higher risk of becoming depressed.

Depression may be intensified by the use of alcohol, which, in turn, makes suicidal behavior more likely. Alcohol also reduces self-control. 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.

Other mental health disorders besides depression also put people at risk of suicide. People with schizophrenia or other psychotic disorders may have delusions (fixed false beliefs) that they find impossible to cope with, or they may hear voices (auditory hallucinations) commanding them to kill themselves. People with borderline personality disorder or antisocial personality disorder, especially those with a history of violent behavior, are also at higher risk of suicide.

Antidepressants and the risk of suicide

The risk of suicide attempts is greatest in the month before starting antidepressant treatment, and the risk of death by suicide is no higher after antidepressants are started. However, antidepressants slightly increase the frequency of suicidal thoughts and behaviors (but not of completed suicide) in children, adolescents and young people. So parents of children and adolescents should be warned, and children and adolescents should be carefully monitored for side effects such as increased anxiety, agitation, restlessness, irritability, anger, or a shift into hypomania (when people feel full of energy and cheerful but are often easily irritated, distracted, and agitated) especially in the first few weeks after they start taking the drug.

Because of public health warnings about the possible association between taking antidepressants and an increased risk of suicide, doctors started prescribing antidepressants about 30% less often for children and young people. However, during this same time, suicide rates among young people temporarily increased by 14%. Thus, it is possible that by discouraging drug treatment of depression, these warnings resulted in more, not fewer, deaths by suicide.

When people with depression are given antidepressants, doctors take certain precautions to reduce the risk of suicidal behavior:

  • Giving people antidepressants in amounts that would not cause death

  • Scheduling more frequent visits when treatment is first started

  • Clearly warning people and their family members and significant others to be alert for worsening symptoms or suicidal ideation

  • Instructing people and their family members and significant others to immediately call the doctor who prescribed the antidepressant or to seek care elsewhere if symptoms worsen or suicidal thoughts occur

Did You Know?

  • Taking antidepressants has been linked with an increased risk of suicidal thoughts and attempts, but not taking antidepressants may increase the risk of suicide much more.

  • Although most men and women who kill themselves use guns, more than twice as many men complete suicide this way.

Methods Used for Suicide

The choice of method is often influenced by cultural factors and availability. It may or may not reflect the seriousness of intent. Some methods (such as jumping from a tall building) make survival virtually impossible, whereas other methods (such as 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.

Suicide attempts most often involve drug overdose and self-poisoning. Violent methods, such as shooting and hanging, are uncommon among suicide attempts because they usually result in death.

For completed suicides, men most commonly use firearms (56%), followed by hanging, poisoning, jumping from a height, and cutting. Women most commonly use poisoning (37%), followed by firearms, hanging, jumping from a height, and drowning.

Prevention of Suicidal Behavior

Although some attempted or completed suicides come as a shock even to family members and friends, many people give clear warnings. Any suicide threat or suicide attempt must be taken seriously. If it is ignored, a life may be lost.

If a person is imminently 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 may hospitalize people who have threatened or attempted suicide. Even if they do not agree to hospitalization, most states allow a doctor to hospitalize people against their wishes if the doctor believes that they are at high risk of harming themselves or other people.

Management of Suicidal Behavior

Doctors take any suicidal act, regardless of whether it is a gesture or an attempt, seriously.

If people seriously injure themselves, doctors evaluate and treat the injury. If people have taken an overdose of a potentially lethal drug, doctors immediately take steps to prevent absorption of the drug and speed its elimination from the body. People are also given any available antidote and provided with supportive care, such as a breathing tube.

After the initial evaluation, people who have attempted suicide are referred to a psychiatrist, who tries to identify problems that contributed to the attempt and plan appropriate treatment.

Because depression increases the risk of suicidal behavior, doctors carefully monitor people with depression for suicidal behavior and thoughts.

Impact of Suicide

Death by suicide has a marked emotional effect on all involved. Family, friends, and doctors 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 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, maintain directories of local support groups. Resources are also available on the Internet.

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.

Physician Aid in Dying (formerly, Assisted Suicide)

Physician aid in dying refers to the assistance given by physicians to people who wish to end their lives. It is very controversial because it reverses the doctor's usual goal, which is to preserve life. Physician aid in dying is illegal in all states except Oregon, Washington, Montana, Vermont, and California. In the rest of the United States, doctors can provide treatment intended to minimize physical and emotional suffering, but they cannot intentionally hasten death.

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