Suicide

Suicide, the deliberate taking of one’s own life, is usually the result of a psychiatric disorder, although sometimes deliberated in the face of life-threatening physical illness, significant interpersonal stress, or when under the influence of one or more substances of abuse.

ANATOMY OR SYSTEM AFFECTED: Psychic-emotional system, all bodily systems

Causes and Symptoms

Suicide is the deliberate taking of killing oneself. Most often, suicidal individuals are trying to avoid emotional or physical pain that they believe they cannot bear; sometimes, they are very angry and take their lives to lash out at others. Suicide is seen as a solution to an otherwise insoluble problem. The World Health Organization (WHO) indicated in 2023 that an estimated 700,000 suicides occurred worldwide each year, with suicide noted to be the fourth leading cause of death among fifteen- to twenty-nine-year-olds worldwide. In the United States in 2023, according to the Centers for Disease Control and Prevention (CDC), there were over 50,000 suicide deaths; that year the country's suicide rate reached an all-time high.

Women attempt suicide more often than men, but men die by suicide more often than women because men tend to use more lethal means, such as firearms. In high-income countries, adolescents and older adults are high-risk groups, while in low- and middle-income countries, adults in middle age are at greater risk, according to the WHO. In 2023, according to the WHO, 77 percent of global suicides occur in low- and middle-income countries.

Most suicidal people in high-income countries experience suicidal thoughts as a result of a psychiatric disorder. The suicidal thoughts and impulses are seen as symptoms of the underlying disorder and require treatment just like any other symptom. The treatment may involve protecting the person against his or her suicidal actions, even to the point of involuntary commitment to a mental hospital. However, many suicides occur when an individual is experiencing a moment of crisis, such as financial problems, job loss or prolonged unemployment, a relationship breakup or divorce, the death of a loved one, or chronic pain or illness. Furthermore, experiencing conflict, environmental disaster, violence, harassment, bullying, or abuse increase the risk of suicidal behavior. Suicide rates are also high among people who experience discrimination, including refugees and migrants; indigenous peoples; lesbian, gay, bisexual, and transgender (LGBTQ+) individuals; and prisoners.

The most common mental health conditions that cause suicidal thoughts are depression, anxiety disorders such as panic disorder, schizophrenia, psychotic disorders, substance use disorders such as alcohol dependence, dissociative disorders such as depersonalization disorder and dissociative identity disorder, conduct disorders, and certain personality disorders such as borderline personality disorder.

Although suicide may occur at any time of the year, there is a seasonal variation in its peak incidence. Suicides are most common in both men and women in late spring and early summer; some studies have attributed this to increases in temperature, levels of sunlight, and/or humidity, but efforts to isolate seasonal variables have led to inconclusive results. Studies have also shown a second, smaller peak in suicide rates in the fall.

Suicide appears to have multiple factors involved in its etiology. There are biological, psychological, social, and contextual factors that interact in a complex way to contribute to the causes of suicide in any given individual. The biological factors include genetic contributions to the development of mood disorders such as depression. This may be attributable in part to problems in the neurotransmitter systems in the brain, such as those that control levels of serotonin and dopamine.

Alcohol and other substances of abuse may also cause suicidal ideation. Suicidal thoughts may occur while the individual is using, intoxicated, or in withdrawal. Paradoxically, suicidal thoughts may also arise while the patient is taking antidepressant medications. Fortunately, this side effect is uncommon, and most antidepressant medications do not have such effects. The fact that suicidal thoughts may occur even when on medication, however, underscores the need for individuals taking medications to stay in regular contact with the prescribing physician and to never discontinue their medication without medical consultation. If family members observe a relative who is taking antidepressants becoming more depressed, hostile or angry, or suddenly happy or relieved, or if the individual has no apparent response to the medication, then it would be wise to consult with the prescribing physician. This is especially true for family members of children or elders on antidepressant medication.

Psychological factors contributing to suicide include a depressed and/or anxious mood, hopelessness, and a loss of normal pleasure in life activities. Chronically depressed people often experience diminished problem-solving skills during periods of depression and have trouble seeing a way out of their difficulties; suicide is seen as the only solution.

The social factors involved in suicide include cultural acceptance or rejection of suicide. Historically, Japanese culture has accepted ritual suicide in some circumstances and have somewhat sanctioned suicide as a response to a severe loss of face or social esteem. This does not mean that Japanese culture embraces suicide, but rather that the history contributes to cultural norms where this is thought of as an option for dealing with shame. Similarly, in 2002, the Dutch government legalized euthanasia and physician-assisted suicide in certain cases of terminal illness. In contrast, most Americans have a more negative view of the act of suicide, although some states have permitted physician-assisted suicide (but not euthanasia). Other social factors that increase the likelihood of suicide include social instability, divorce, unemployment, immigration, loss, and exposure to violence or abuse as a child. In the United States, adults who are biracial and American Indians, Native Hawaiians, and Alaska Natives have the highest incidence of suicide. In general, good social support reduces the risk of suicide.

Researchers have also noted that people working in certain occupations may be at a disproportionate risk of dying by suicide. For example, researchers in the US, drawing on data collected by the CDC, found that in 2022 construction workers, particularly men working in that industry, experienced a suicide rate 75 percent higher than the general population. The researchers cited, among other factors, long hours and stressful working conditions as a possible cause, along with substance abuse and financial instability among some workers in this industry. That year, the CDC also identified high suicide rates among workers in other industries, including agriculture and entertainment.

Some patients engage in suicidal gestures; that is, they say they want to kill themselves and take actions such as swallowing pills or cutting their wrists, but there is no real intention to die. They act this way as a cry for help. For some, this may be the only way to receive attention or support for what troubles them. Unfortunately, the suicide gesture may go awry, and unintended death may occur. Anyone who speaks of suicide or engages in what may appear to be a gesture should be taken seriously.

Most people who are suicidal have ambivalent feelings: part of them wants to die, and part does not. This is one of the reasons that the majority of suicidal people tell others of their intention in advance of their attempts. Most visit their personal physician in the months prior to the suicide. Adolescents sometimes hint at their wish to die by giving away their prized possessions prior to an attempt.

Contextual factors, or the circumstances in which people find themselves, can also contribute to individuals attempting suicide. Access to means of self-harm, such as firearms, alcohol, or drugs, can increase the likelihood of a suicide attempt. Complex social situations involving conflict can lead to the use of suicide bombings or other suicidal attacks as a military tactic or an act of religious or symbolic martyrdom. Physical isolation from others can also increase the odds, as there is no one to readily intervene or offer support. Even painful emotional or physical states, such as exhaustion or a state brought on by substance use, can set the stage for impulsive behavior and increase the likelihood of suicide attempts. However, many people are worried about asking someone if they are considering suicide, fearing that they will put the idea into their head, but, in fact, this may be the best way to offer support and get the person to seek help from a therapist or other medical professional.

Anyone experiencing suicidal thoughts should seek the care of a professional trained in the assessment of suicidal patients. If the risk of suicide is considered to be high enough, the patient may have to be protected. This may require hospitalization, either voluntary or involuntary. It may mean removing suicidal means from that person’s environment, such as removing guns from the home. Having someone stay with the patient at all times may be required. These steps should be individualized, taking into account the patient’s situation and preferences, where possible.

Treatment of the underlying cause of the suicidal ideation is crucial. Depression and anxiety can be treated with psychotherapy and/or medications. Cognitive behavioral therapy has been shown to be effective in reducing suicide risk. Dialectical behavior therapy (DBT) is effective at reducing the rate of suicide among people with borderline personality disorder. DBT teaches individuals how to identify when certain actions or feelings are disruptive or unhealthy and offers new coping skills. Other common types of psychotherapy for depression include interpersonal therapy, behavioral activation, and cognitive behavioral analysis system of psychotherapy. There are treatment programs for alcoholism and drug abuse. Usually, successful treatment of the underlying psychiatric disorder results in the suicidal thoughts going away. While they await the resolution of the suicidal ideation, patients need to be offered support and hope.

Suicide prevention includes the early detection and management of the mental disorders associated with suicide. Warning signs of suicide include talking about being a burden to others, about feeling trapped, about experiencing unbearable pain, about having no reason to live, or about killing themselves. Other behaviors that can indicate suicidal ideation are increased use of alcohol or drugs, acting recklessly, isolating oneself from family and friends, withdrawing from activities, sleeping too much or too little, visiting or calling people to say goodbye, or acting aggressively. Because social isolation increases the risk of suicide, patients should be encouraged to develop and actively maintain strong social supports such as family, friends, and other social groups (e.g., church, clubs, or sports teams).

It may also be helpful to provide counseling to individuals after a friend or acquaintance has died by suicide, as this may prevent social contagion and suicide clusters. A suicide cluster is when several individuals, often teenagers, die by suicide after learning of the suicide of an acquaintance or a person who is attractive to them, such as a famous musician or film star. Exposure to another person's suicide or to graphic or sensationalized accounts of suicide increase suicide risk.

Family members of a suicide victim often go through a grieving process that can often be more severe than that which occurs after death from other causes. The stigma of suicide and mental illness is strong, and surviving family members often have greater feelings of guilt and abandonment. Family survivors also have increased psychosomatic complaints, behavioral and emotional problems, and risk of suicide themselves. Referral to a suicide survivor group may be helpful.

Treatment and Therapy

An understanding of the causes, detection, and treatment of suicide has led to the development of a number of suicide hotlines and suicide prevention centers. There is evidence that after these support groups are introduced into a community, the suicide rate decreases.

Most people who contemplate suicide do not seek professional treatment, even if they tell people around them of their suicidal ideas. Thus, it is important for physicians, clergy members, teachers, parents, and mental health workers to remain alert to the possibility of suicidal thoughts in those under their care. Someone who is depressed or anxious should be asked about suicidal thoughts. Such a question will not plant the idea in the person's head, and they may feel relieved after being asked. Once someone with suicidal ideation is identified, evaluation and treatment should proceed quickly. The following sample composite cases illustrate the application of the concepts described in the overview.

Mary is a seventeen-year-old senior in high school. She was severely abused by her father before her parents' divorce ten years ago. Her teachers think that she is a bright underachiever who has a rather dramatic personality. Her friends see her as moody and easily angered. Her relationships with boyfriends are intense and always end with deep feelings of hurt and abandonment. Her mother is best described as cold, aloof, and preoccupied with herself.

Mary is brought to the school counselor by one of her friends when Mary threatens to kill herself and superficially scratches her wrists with a safety pin. The counselor learns that Mary has just broken up with her boyfriend, a young man at a local junior college, and is devastated. When she tried to tell her mother about it, her mother seemed uninterested and said that Mary always makes too much of such little things. It was the next morning that she scratched herself in front of her friend.

While more information is needed, this case illustrates a suicidal gesture. In this case, Mary does not want to die, but she wants someone to realize how distressed she is. She feels rejected by her boyfriend and then by her mother. Suggestions that this is a gesture rather than a serious suicide attempt include the superficial, nonlethal means (scratching with a safety pin) and the likelihood of discovery (done in front of a friend). Nevertheless, all suicidal gestures should be taken seriously, and professional and social support must be offered.

Here is a second case. Tom is a forty-eight-year-old accountant. He is separated from his wife and three children and lives alone in an apartment. He has no real friends, only drinking buddies. Like his father and two uncles, Tom is an alcoholic. Each day after work, he stops at his favorite bar and drinks between eight and twelve beers.

He is brought to the emergency room of the local hospital by the police, who found him sitting on the steps of a church, sobbing. He threatened to kill himself if his wife did not take him back. The emergency room doctor noted the strong odor of alcohol on his breath and ordered a blood alcohol test, which indicated that he was legally intoxicated. Tom insisted that he would kill himself by running in front of a moving bus if he could not be with his family. The emergency room doctor had Tom’s belt, pocketknife, and other potentially dangerous items taken from him and arranged for a staff member to sit with him until he was sober. Six hours later, his blood alcohol had returned to near zero. Tom no longer felt despondent and had no more suicidal thoughts. He was embarrassed by his statements a few hours before. An alcoholism counselor was called, and outpatient treatment for his alcoholism was arranged.

This case illustrates suicidal ideation caused by alcohol intoxication. As often happens, the suicidal ideation resolves when the patient becomes sober. The primary treatment is for the underlying addictive disorder.

Here is a third case. Sally is a fifty-three-year-old married mother of two. She is a part-time hairdresser and normally a very active, happy person. For the past three months, however, she has gradually lost all interest in her job, her children, her home, and her hobbies. She feels irritable and sad most of the time. Although she is tired, she does not sleep well at night, waking up very early each morning, unable to return to sleep. She is worried about the fact that she is having intrusive thoughts of killing herself. Sally imagines she could end all this dreariness by overdosing on sleeping pills and never waking up. She is a strict Catholic and knows it is against her religion to die by suicide. She calls her parish priest.

After a brief conversation, her priest meets her at the office of a psychiatrist who acts as a consultant for the diocese. The psychiatrist diagnoses major depression as the cause of Sally’s suicidal ideation. She has a good social support network, so the psychiatrist decides to treat her as an outpatient. Sally is also started on antidepressant medication, which gradually lifts her depression over a period of two to three weeks. Simultaneously, her suicidal thoughts leave her.

This case illustrates suicidal thoughts caused by depression. If Sally had been more severely depressed or her suicidal urges stronger, she would probably have needed hospitalization. If she had required hospitalization and had refused to go voluntarily, the psychiatrist may have had her committed according to the laws of the state where he practiced. Most states require a signed statement by two physicians or one physician and a licensed clinical psychologist. They must attest that the patient is a danger to themselves and that no less restrictive form of treatment would suffice.

Finally, here is a fourth case. Harry is a sixty-seven-year-old resident of a hospital where he has been for the past two years. He has a serious neurological disorder called amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease. It has caused progressive weakness such that he cannot even breathe on his own. Harry is permanently connected to a respirator attached to a tracheotomy tube in his throat. He has few visitors and mostly stares off and thinks.

Harry tells his nurse that he is “sick of it all” and wants his doctors to disconnect him from the respirator and let him die. His neurologist requests a psychiatric evaluation. The psychiatrist confirms the patient’s wish to die. There is no evidence of dementia or other cognitive disorder, nor is the patient showing any evidence of a mental illness. Subsequently, a meeting is called of the hospital ethics committee to make recommendations. Members of the committee include physicians, nurses, an ethicist, a local minister, and the hospital attorney.

This case illustrates a difficult example of a rational suicide request. The patient has a desire to die and is not suffering from any mental disorder. In this case, he is requesting not to take his own life actively, but to be allowed to die passively by removal of the respirator. Some people do not consider this to be suicide at all. They make a distinction between passively allowing a natural process of dying to occur and actively taking one’s own life. If this patient requested a lethal overdose of potassium to be injected into his intravenous tubes, such action would be considered physician-assisted suicide and ethically different.

Perspective and Prospects

Throughout history, there have been numerous examples of suicide. In Western culture, early views on the subject were mainly from a moral perspective, and suicide was viewed as a sin. Mental illness in general was poorly understood and often stigmatized as weakness of character, possession by evil spirits, or willful bad behavior. Even though society now has a better medical understanding of mental illness, there is still a stigma attached to mental illness and psychotherapy. This stigma contributes to underdiagnosis and undertreatment of suicidal individuals, as many sufferers are reluctant to come forth with their symptoms.

Suicide remains an important public health problem. In 2021, it was the tenth most common cause of death for all ages in the United States and the second leading cause of death among those between the ages of ten and thirty-four. Each year, there are more than thirty thousand known suicides in the United States. Worldwide, an estimated 700,000 people die by suicide every year. The actual incidence may be higher because an unknown number of deaths may not be identified as suicides. For every suicide death, between eight and twenty-five other individuals attempt suicide. Because of the rising number of suicides, as well as drug overdoses, life expectancy in the US declined for several years in the late 2010s and early 2020s. Teenage suicide was seen as a particularly growing problem, often linked in the popular media to increased social pressures, including through social media.

The US government has taken some steps at a national level to address suicide, notably the creation of a National Suicide Prevention Hotline through the National Suicide Hotline Designation Act of 2020. This bipartisan legislation, which designated 988 as the national contact number for individuals experiencing a mental health crisis or suicidal thoughts, or anyone concerned about an individual experiencing these things, involved the efforts of the US Department of Health and Human Services (HHS), the Federal Communications Commission (FCC), and the Department of Veterans Affairs (VA). The 988 hotline in the US became active in July 2022. Numerous other countries, such as Australia, Brazil, and Canada, have their own national suicide hotlines.

Tragically, most cases of suicidal ideation never come to the attention of health professionals. Therefore, when someone talks of suicide, a high level of attention and care should be maintained. People who express suicidal thoughts should be taken seriously, offered support, and thoroughly evaluated. Increased levels of awareness of suicide may help improve detection and treatment of this potentially preventable cause of death. Research in this area continues to focus on prevention, early identification, and treatment for individuals who are distressed.

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