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Preventing Suicide: Individual Acts Create a Public Health Crisis

cont.

The Issue:

Every day, on average, more than 80 Americans take their own lives, and an estimated 1,500 more attempt suicide. (1) Although rates for teens and young adults appear to be declining, deaths from suicide in these age groups are still more frequent than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease combined. Americans 65 years and older have higher rates of suicide than any other age group, with the highest rate of suicide occurring among white men over the age of 85.

The Facts:

• Suicide is the 11th leading cause of death in the U.S. population. In 2000, 28,332 Americans died from suicide, a rate of 10 deaths for every 100,000 people.

• In 1999, the most recent year for which homicide data are available, there were nearly twice as many suicide deaths (29,199) as homicides (16,899).

• Suicide rates in adolescents peaked in the early 1990s, but rates may be decreasing for most groups of teens. Suicide is still the third-leading cause of death for adolescents and young adults, and in 1997 accounted for 12 percent of deaths in those aged 10-24.

• Young people age 12-17 who reported alcohol or drug use were more likely to be at risk for suicide, and only 36 percent of young people at risk received treatment or counseling.

• African American, Hispanic and white teens are less likely to attempt suicide if they feel a connection to their parents and family. For girls, emotional well-being also helps. For boys, a high grade point average is related to lower suicide risk.

• Rates of suicide among African American adults tend to be lower than in the general population and rates for African American women are low across the lifespan. Rates are highest in white men over the age of 85.

• Among young people, American Indian and Alaskan Native adolescents have the highest rates of suicide. A nationwide survey of high school students in 1999 also found that Hispanic students were more likely than non-Hispanic black or white students to report a suicide attempt.

• Youth surveys indicate an increased risk of suicidal behavior and thoughts, but not completion, in students who self-identify as gay, lesbian or bisexual, (3) and a higher risk of actual attempts in boys who report same-sex attractions.

• In 1999, 242 children age 10-14 committed suicide, a rate of 1.2 deaths for every 100,000 people.

• The most common method of suicide for both men and women is by firearms, accounting for 57 percent of all suicides in 1999.

• More than 90 percent of completed suicides occur in individuals with depression or another diagnosable mental or substance abuse disorder.

• People with a parent, sibling, aunt, uncle or grandparent who attempted or died from suicide are at increased risk for suicide and attempts.

Suicide reporting in the media can contribute to suicide contagion: Newspaper and television reports of suicide have been linked to increases in suicide rates. The degree to which rates increase is a function of the amount, duration and prominence of media coverage of suicide.

Interview:

Growing Pains:
Adolescent Suicide Rates Raise Concerns

Madelyn S. Gould, Ph.D., M.P.H., is a professor of psychiatry and public health/epidemiology at Columbia University's College of Physicians and Surgeons and a research scientist at the New York State Psychiatric Institute. Dr. Gould's work has included projects examining risk factors for teenage suicide, various aspects of cluster suicides, the impact of the media on suicide, the effect of suicide on fellow students, and the evaluation of suicide prevention programs, such as telephone crisis services for teenagers.

Q. Rates of suicide among adolescents and young adults have been the source of tremendous concern. These rates tripled between 1952 and 1995. (19) What is happening with teen suicide rates now?

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A. Although rates of suicide and suicide attempts among teens and young adults remain distressingly high, the good news is that suicide rates for some adolescents appear to have gone down in the past few years. For example, suicide rates for African American males increased rapidly between 1986 and 1994 but had decreased significantly by 1997. Rates for white males also have fallen since a peak in the early 1990s. Rates for girls, which are much lower than rates for boys, did not show the same types of increases and have stayed fairly constant over the past 20 years.

Q. Are there specific factors that have been identified as contributing to these decreases?

A. One important factor appears to be improvements in the treatment of depression. This includes the increased use of SSRIs (serotonin selective reuptake inhibitors), drugs used to treat affective illnesses, among teens and young adults.

Q. There are gender differences in suicide attempt and completion rates among adults. Is this also true for adolescents and young adults?

A. Attempted suicide rates are higher among girls and completed suicide rates are higher among boys. As with older individuals, in teens and young adults these differences appear to result from the methods chosen. Girls and women are more likely to use drug overdose; boys and men are more likely to use firearms or hanging.

But firearms kill girls, too. If that is the method chosen, it is likely to result in a completed suicide in girls and boys.

Q. What are the most common risk factors for suicide and suicide attempts in adolescents and young adults?

A. Research on adolescents and young adults is producing converging evidence about factors that increase risk for suicidal behavior and suicide completion. Psychological autopsies are studies of individuals who have committed suicide; studies have produced information that is similar to the patterns emerging from epidemiological studies of young people who have attempted suicide. Taken together, these different types of studies indicate that major psychiatric disorder is an important risk factor for suicide and suicide attempts.

Mood disorders, for example, have been shown consistently to increase suicide risk. Substance abuse also has been identified as a risk factor, but substance abuse itself is more common among older boys, so patterns of risks associated with using drugs or alcohol may be different in different age and gender groups.

Q. What other types of risk factors have been identified?

A. A family history of suicidal behavior greatly increases the risk in teens and young adults. This may have a genetic component, which in turn may be related to serotonin problems.

Poor parent-child relationships are associated with increased risk. Other factors that increase risk for suicidal ideation and attempts include parental mental illness and substance abuse.

Other factors that appear to increase risk for suicide include a sense of hopelessness and the occurrence of stressful life events.

Q. Are there specific life stressors that increase suicide risk for teens?

A. It appears that two types of events may trigger suicidal behavior in some individuals: interpersonal losses (such as the break up of a relationship) and legal or disciplinary problems. It is important to emphasize, though, that it appears that it is the combination of stressful life events with an underlying vulnerability, such as a depressive illness, that results in increased risk.

Q.Is suicide risk higher for some adolescents and young adults?

A.Some studies have indicated that sexual orientation - self-identifying as gay or lesbian - increases the risk for suicidal behavior and thoughts, but not for completed suicide. Also, African Americans have historically had much lower rates of suicide than whites, but between 1986 and 1994, rates of completed suicide among African American males almost caught up to rates for white males in the 15-19 age group.

Q. What explains these differences?

A. It is unlikely that the difference between suicide rates in African American youth and white youth is attributable to stress - if that were true, one would expect that rates in African Americans would be far higher than in whites. So it's possible that some other type of factor is operating. But there have been far fewer studies on factors that protect teens and young adults from suicide than studies on increased risk. It has been suggested, though, that religiosity, in its social support aspect rather than its spiritual aspect, may help teens and young adults in some sub-groups.

Q.Are there other factors that influence teens and young adults?

A. Many studies indicate that suicide contagion and imitation are real. The studies show increases in rates of completed suicides and attempts after news accounts of suicide. Though the results are less consistent, some studies also show that fictional TV shows with suicide content also have an impact on rates of suicide and attempts.

These factors increase risk, but not to the same degree as psychiatric disorders do. Suicides in clusters account for about 1 percent to 5 percent of teen suicides in the United States, though rates vary by state and by year.

Q. What can prevent suicide efforts in children, teens and young adults?

A. There are two central components of successful prevention programs. The first is case-finding, which involves efforts to find kids who are at risk, referring them for services and making sure they get appropriate care. The second is risk reduction or primary prevention. This means reducing the risks for suicide and suicidal behavior in the general population, for example, by restricting access to lethal means.

Other preventive strategies that have been shown to hold promise are programs to train community helpers, such as police, clergy, coaches and other natural helpers, to recognize the signs. Training programs with general practitioners and other physicians in recognizing suicide risk and in the use of antidepressants are also effective.

In contrast, evaluations of suicide awareness curricula through schools indicate that they are not effective and are not recommended. Other school prevention programs involving skills training appear to be more promising.

At a more general level, the National Strategy for Suicide Prevention released last year by the federal government is a good example of a comprehensive, coordinated effort that has the potential to be very successful in preventing suicide and suicidal behaviors.

Answering a National Call to Arms

The National Strategy for Suicide Prevention is a comprehensive public health initiative by the U.S. Department of Health and Human Services and partners including the National Council for Suicide Prevention. The NSSP is intended "to be a catalyst for social change with the power to transform attitudes, policies and services." The NSSP aims to:

• prevent premature deaths due to suicide across the life span

• reduce the rates of other suicidal behavior

• reduce the harmful after-effects associated with suicidal behaviors and the traumatic impact of suicide on family and friends

• promote opportunities and settings to enhance resiliency, resourcefulness, respect and interconnectedness for individuals, families and communities.

The NSSP can be ordered at www.mentalhealth.org. Additional information and other resources are also available at that address.

An Age-Old Dilemma:
Elderly Americans Have Highest Rates of Suicide

Yeates Conwell, M.D., is professor and associate chair for academic affairs in the Department of Psychiatry at the University of Rochester School of Medicine. He is a geriatric psychiatrist whose research interests focus on late-life affective disorders and suicidal behaviors. He is co-director of the Center for the Study and Prevention of Suicide at the University of Rochester School of Medicine and consults with organizations worldwide on these topics.

Q. Suicide is increasingly perceived as a public health problem rather than an act by an individual. What has contributed to this change?

A. This change, which is still taking place, has been the result of a process that has evolved over the past 10 to 15 years. In the past, the stigma of suicide kept it in the closet, leaving affected individuals and families in isolation. Stigma also kept suicide from being identified as a public health problem. This was partly because suicide was seen as the province of psychiatry, which operated on a medical model of illness, diagnosis and treatment of individuals. More recently, health care systems have taken a public health perspective, in which problems that afflict communities are identified for prevention. Suicide is certainly one of the preventable public health problems that stands out.

Changes have also resulted from work by individuals and advocacy groups on the political process. In 1997, the U.S. Senate and House adopted resolutions recognizing suicide and suicide prevention as public health issues. In 1999, former Surgeon General David Satcher released the Surgeon General's Call to Action to Prevent Suicide which led to the collaborative development of the National Strategy for Suicide Prevention by agencies of the U.S. Department of Health and Human Services, health care providers, consumers and their families. The NSSP was released last year.

Q. What causes people to take their own lives?

A. There is no one cause of suicide - it is the result of a combination of factors. Current thinking falls into three major categories: biological, psychological and social. Biological theories address the possibility that there are physiological factors, such as an imbalance of neurotransmitters - serotonin especially - that create a predisposition toward suicidal behavior. The role of biology in depression, aggression and impulsive behaviors in suicide attempts and completed suicides is being studied.

With respect to the psychology of suicide, no theory is predominant. But an interesting possibility is the role played by attachments in early development and the ability of individuals to form and maintain stable relationships. Disruptions in relationships increase the risk of depression and also the risk for suicide in some groups.

Social theories can be traced to the work of Emile Durkheim in the late 19th century. Durkheim hypothesized that connectedness of people to their society and the meaning that they find in their larger social contexts are important factors in suicide.

All three theories are important ways of thinking about suicide, and they all have implications for prevention and intervention.

Q. How are the factors that contribute to completed suicides investigated?

A. Most data on risk factors for suicide come from "psychological autopsy" studies. These studies reconstruct circumstances surrounding a suicide by talking with family members, friends, and sometimes employers and health care providers. Psychological autopsy studies also often involve a review of medical records. Using this, a person's background, developmental history, symptoms, illnesses, stressors, and social circumstances help form a qualitative understanding of the person prior to suicide.

In an increasing number of studies, this information is used to determine whether there are patterns in the characteristics that distinguish people who commit suicide from similar people who are not suicidal. These studies offer a rich understanding of people who typically have not been seen in mental health settings prior to their deaths.

Other types of studies are being conducted as well. These include studies over time of large numbers of people in the general population, a small number of whom eventually take their own lives, or attempt to do so. This makes it possible to gather information prior to suicide attempts or completions and to identify factors related to increased risk.

Q. Based on existing research, who is most likely to die by suicide?

A. Although specific risk factors have been identified, it is difficult to predict who will be a victim of suicide because most people with these risk factors do not try to take their own lives. It appears that a combination of factors contributes to suicide.

The profile of people at risk for suicide also changes somewhat across the life course. Many younger people struggle with issues of relationships, financial problems, problems with drug and alcohol, legal problems and chaos in their lives in general. In middle age, suicide risk appears to be related to relationship problems, substance abuse disorders and psychotic illness. In later life, people have generally been survivors, so the issues are a little different. Risk appears to be related to depression, the inability to cope with the crescendo of stressors having to do with loss and life change, and the absence of sufficient social support.

Q. Are there other factors that distinguish suicide risk and suicide completion in older adults?

A. The rate of suicide among older people in the United States is higher than any other age group. This comes mostly from the very high rates of suicide among white males in later life. Males age 85 and up are at highest risk for suicide - about six times higher than the nation as a whole. The pattern is different for women. Although women attempt suicide more often, rates of completed suicide are much lower for women than for men.

Rates tend to peak in midlife, then remain stable or decline slightly, for women in the United States.

Older people who kill themselves are less likely than younger suicide victims to have attempted it previously. Also, older individuals who take their own lives are more likely to have suffered from a depressive illness than people who kill themselves at younger ages.

Q. What are some characteristic signs of depression in later life?

A. It is important to distinguish between depression or sadness as a temporary mood and depression as an illness. The illness is often called clinical depression. Its characteristics include loss of interest in activities, difficulty concentrating, low energy, increases or decreases in appetite, sleep disturbances, hopelessness or a bleak outlook toward the future, sadness, guilt and thoughts of suicide or death. In older people, depressive illness may be more likely to express itself in loss of energy and loss of interest rather than feeling sad or feeling like crying.

Q. Are there other signs and symptoms to watch for?

A. Suicide can be related to stressful circumstances, including losses and physical problems, which also increase the risk for depression. So times of loss or other stressful events may be a time for increased concern. Older people who are suffering from depressive illness may become withdrawn and less communicative, begin drinking more alcohol or stop caring for themselves as well as they have in the past.

Other signs of depressive illness or increasing suicide risk include giving away possessions, using medications inappropriately and acquiring potential methods for suicide (for example, obtaining firearms or stockpiling medications). Some symptoms may be mistaken for common reactions to the stresses of aging. But it is critical to recognize that depression is not a normal part of aging. It is not normal for people to lose interest in things that they have enjoyed doing or to experience a profound loss of energy.

Q. What steps should be taken if concerns arise?

A. It is important to simply ask people how they are - to sit and talk and ask how they are doing. Older individuals also may not appreciate that what they are feeling and experiencing is not normal. It is extremely useful to understand how older people feel about their circumstances and their lives under everyday circumstances and under unusual conditions.

Sometimes people hesitate to ask whether someone they care about is having suicidal thoughts out of a fear that they will "put the thought in their heads." This is a myth.

It is also a myth that people who talk about suicide are less likely to take their own lives. This is not true - talking about suicide is a signal that something is wrong and that additional help is needed.

Q. Are there effective strategies for preventing suicide in the elderly?

A. Just as there is no single factor that causes suicide, no single intervention is going to prevent all suicides. The success of prevention efforts depends on the "alterability" of factors that contribute to suicide. But there are many factors that can be changed or enhanced that will help reduce the risk of suicide in older people.

We know, for example, that social support - having strong connections to family and community - protects against suicide risk. Receiving effective care for mental, physical and substance abuse disorders is another protective factor.

Providing access to adequate health care and social services is critical, as is providing support to the health care system to assure adequate diagnosis and management of pain, impairment and physical illness in the elderly. Older people who receive the best care are going to want to live and we all have a role to play in making sure our elderly population is cared for well.

Help or Harm?
The Controversy Over Assisted Suicide

One of the more controversial and hotly debated ethical and legal issues has been the question of whether physicians should be allowed to help terminally ill patients end their lives.

A recent Harris Poll indicates that a majority of adults in the United States support the right to physician-assisted suicide for patients who are believed to have fewer than six months to live. When asked by Harris whether the law should allow doctors to comply with the wishes of a dying patient in severe distress who asks to have his or her life ended, 65 percent of the adults surveyed said yes. Sixty-one percent also said that they would favor a law in their own states like Oregon's "Death with Dignity Act," a citizens' initiative that was approved by voters in 1994 and again in 1997.

In North America, two arguments have traditionally been advanced in support of physician-assisted suicide, says Sandra J. Taylor, Ph.D., co-author with Carlos Prado of Assisted Suicide: Theory and Practice in Elective Death (Humanities Press, 1999).

The arguments are respect for autonomy/self-determination and mercy/compassion. In the autonomy view, competent individuals should be able to exercise control over their own lives and deaths. In the mercy view, it may not always be possible to alleviate suffering, therefore assistance in dying may be a compassionate response.

Arguments against physician-assisted suicide typically have been based on the principle of the sanctity of life and the potential for the abuse of the option of assistance by overburdened family members or care providers.

A debate continues among health care providers and in the bioethics literature regarding the distinction between passively letting someone die (for example, through cooperating with their refusal of treatment) and actively assisting someone in dying. "The law treats these actions differently now," says Taylor, "but many ethicists will argue that they are the same."

Dr. Taylor, an associate professor of medicine and clinical bioethicist at Queen's University in Kingston, Ontario, suggests that it is fundamentally important to understand that people commit suicide for different reasons and to evaluate those reasons. In cases in which a person's reasoning is skewed because of depression or other mental illness, suicide clearly would be considered 'irrational.' In such cases, the illness causing the skewed worldview should be treated and assistance is unambiguously not at issue.

"On the other hand," says Taylor, "some will argue that suicide can be 'rational' in the realm of terminal illness or untreatable suffering. It is in these instances that discussion of assisted suicide might take place."

Responsible Reporting:
Media and Suicide Contagion

Research indicates that media reports and fictional presentations of suicide affect suicidal behavior and contribute to suicide contagion.

Suicide contagion is "the process by which a prior suicide facilitates the occurrence of a subsequent suicide." In addition to contagion through exposure to media reports of suicide, contagion can occur through exposure to suicide or suicidal behaviors within family or peer groups. Suicide contagion affects individuals already at risk for suicide and is linked to increases in suicidal behaviors especially in adolescents and young adults.

In response to this evidence, a group of agencies has released recommendations for media coverage of suicide. The recommendations were developed by the Annenberg Public Policy Center of the University of Pennsylvania, the American Foundation for Suicide Prevention, Office of the Surgeon General, the Centers for Disease Control and Prevention, the National Institute of Mental Health, the World Health Organization and other national and international agencies. They have been widely disseminated to the media, including every newspaper in the country and all college newspapers.

The media can help educate the public about suicide and suicide prevention, but "the job of the media is to decide when suicide is newsworthy," says Kathleen Hall Jamieson, Ph.D., dean of the Annenberg School of Communications at the University of Pennsylvania and director of the Annenberg Public Policy Center. When it is, she says, "the reporter's obligation is to get the story right." This includes understanding the complex causes of suicide and the roles played by mental disorders, substance abuse disorders and other predisposing factors in suicide and suicidal behavior.

In addition to recommended language and suggestions for angles to pursue and stories to consider covering, the recommendations document research on the media and suicide contagion and list resources for additional information about suicide and suicide prevention.

Reporting on Suicide: Recommendations for the Media is at www.appcpenn.org.

Explaining the Gender Gap

Women in the United States attempt suicide far more frequently than men, but rates of completed suicide are higher for men than for women. This pattern is true across age groups in the United States. Similar patterns exist in most other countries as well.

Differences in the rates of completed suicide appear to result from the different methods used. Men are more likely to choose immediately lethal methods such as firearms and hanging. Women tend to choose methods that are less likely to be fatal right away, like drug overdoses or the ingestion of poisons, making discovery and successful treatment more likely.

Researchers have begun to investigate factors influencing the methods people choose and speculate that differences in impulsiveness and aggression between men and women may play a role. Women also may be more concerned about violence and disfigurement. Some researchers also speculate that higher rates of deliberate self-harm in women may indicate that they are less intent on suicide, and that they use self-harm to signal distress.

Other factors that may lead to differences in rates of completed suicides include differences between men and women in patterns of social interaction, including forming and maintaining close social ties. In elderly people, a higher proportion of men who completed suicide were single or divorced.

Women may also respond more favorably to treatment for depression and other psychiatric illnesses, leading to decreased risk for suicide attempts and suicide completions. Culture-specific gender roles, such as differences in emotional expression (for example, women in the United States are more likely to disclose emotions) also may play a role in differences in suicide risk for men and women.

The National Hopeline Network 1-800-SUICIDE provides access to trained telephone counselors, 24 hours a day, 7 days a week. Or for a crisis center in your area, go here.

Resources

American Foundation for Suicide Prevention: 1-888-333-AFSP
American Psychiatric Association: 1-800-852-8330
American Psychological Association: 1-800-964-2000
The Center for Mental Health Services
National Adolescent Health Information Center
National Alliance for the Mentally Ill: 1-800-950-6264
National Depressive and Manic-Depressive Association: 1-800-826-3632
National Mental Health Association: 1-800-228-1114
National Mental Illness Screening Project Suicide Division: 1-800-573-4433
Suicide Awareness/Voices of Education: 612-946-7998
Suicide Information & Education Center: 403-245-3900
Suicide Prevention Advocacy Network: 1-888-649-1366

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