Suicide, intentional, self-inflicted death. A uniquely human act, suicide occurs in all cultures. People who attempt or complete suicide usually suffer from extreme emotional pain and distress and feel unable to cope with their problems. They are likely to suffer from
mental illness, particularly severe
depression, and to feel hopeless about the future.
II PREVALENCE AND TRENDS
Suicide ranks as a leading cause of death worldwide, making it a significant public-health problem. In addition, some researchers believe official statistics underestimate the actual number of suicides.
(A) In the United States
In the United States, suicide ranks in the top ten causes of death, accounting for about 1.5 percent of all deaths. The annual number of suicides has averaged about 30,000 since the late 1980s and has consistently exceeded the annual number of homicides. The suicide rate (number of suicide deaths per 100,000 people) in the United States has remained relatively stable since the 1950s, ranging between 10 and 13 per 100,000 each year.
The suicide rate varies by age group. Of all age groups, the elderly have the highest suicide rates, particularly white men over the age of 75. The increased rate of suicide among elderly people appears mostly due to the debilitating effects of physical illness, loss of social roles and relationships, and untreated
depression. Suicide rates for people between the ages of 15 and 24 tripled between 1950 and 1993. The reasons for this increase are not entirely clear, but researchers have associated it with a greater prevalence of mental illness in young people, an increased use of drugs in this population, and the increased availability of firearms in the home.
Suicide rates also vary between men and women and between ethnic groups. Men complete about 80 percent of all suicides. However, women attempt suicide three times as frequently as men. Among men, Native Americans have the highest suicide rate, followed by whites. White men and women account for about 90 percent of all suicides.
(B) In Other Countries
Canada's suicide rate has historically been similar to or slightly higher than that of the United States. About 3800 suicides are recorded in Canada each year. Countries with the highest suicide rates include Latvia (42.5 suicides per 100,000 people), Lithuania (42.1), Estonia (38.2), Russia (37.8), and Hungary (35.9). Countries with the lowest suicide rates include Guatemala (0.5), the Philippines (0.5), Albania (1.4), the Dominican Republic (2.1), and Armenia (2.3). However, an accurate comparison of suicide rates among countries is difficult because of the unreliability of official suicide statistics and varying methods of certifying how deaths occurred.
Methods of suicide vary from culture to culture. Hanging is the leading method of suicide worldwide. In the United States about 60 percent of all suicides are committed with firearms. In Canada, where guns are less accessible, about 30 percent of suicides are committed with guns. Poisoning, such as taking an overdose of medication, accounts for about 18 percent of U.S. suicides. Researchers believe that a small proportion of fatal single-occupant automobile accidents are actually suicides. Only 15 to 25 percent of those who kill themselves leave suicide notes.
Suicidal behavior has numerous and complex causes. The biology of the brain, genetics, psychological traits, and social forces all can contribute to suicide. Although people commonly attribute suicide to external circumstances-such as divorce, loss of a job, or failure in school-most experts believe these events are triggers rather than causes in themselves.
The majority of people who kill themselves suffer from depression that is often undiagnosed and untreated. Because depression so often underlies suicide, studying the causes of depression can help scientists understand the causes of suicide (see
Depression: Causes). Other mental illnesses, such as bipolar disorder, schizophrenia, and anxiety disorders may also contribute to suicidal behavior.
(A) Biological Perspectives
Research indicates that suicidal behavior runs in families, suggesting that genetic and biological factors play a role in one's suicide risk. Among one community of Amish people in Pennsylvania, almost three-quarters of all suicides that occurred over a 100-year period were in just four families. Studies of twins reared apart provide some support for a genetic influence in suicide.
People may inherit a genetic predisposition to certain psychiatric disorders, such as schizophrenia and alcoholism, that increase the risk of suicide. In addition, an inability to control impulsive and violent behavior may have biological roots. Research has found lower than normal levels of a substance associated with the brain chemical serotonin in people with impulsive aggressiveness.
(B) Psychological Theories
In the early 1900s Austrian psychoanalyst Sigmund Freud developed some of the first psychological theories of suicide. He emphasized the role of hostility turned against the self. American psychiatrist Karl Menninger elaborated on Freud's ideas. He suggested that all suicides have three interrelated and unconscious dimensions: revenge/hate (a wish to kill), depression/hopelessness (a wish to die), and guilt (a wish to be killed).
An American psychologist considered to be a pioneer in the modern study of suicide, Edwin Schneidman, has described several common characteristics of suicides. These include a sense of unbearable psychological pain, a sense of isolation from others, and the perception that death is the only solution to problems about which one feels hopeless and helpless. Cognitive theorists, who study how people process information, emphasize the role of inflexible thinking or tunnel vision ("life is awful, death is the only alternative") and an inability to generate solutions to problems. According to psychologists, many suicide attempts are a symbolic cry for help, an effort to reach out and receive attention.
(C) Sociological Theories
Most social scientists believe that a society's structure and values can influence suicide rates. French sociologist Émile Durkheim argued that suicide rates are related to social integration-that is, the degree to which an individual feels part of a larger group. Durkheim found suicide was more likely when a person lacked social bonds or had relationships disrupted through a sudden change in status, such as unemployment. As one example of the significance of social bonds, suicide rates among adults are lower for married people than for divorced, widowed, or single people.
Studies consistently show that although suicidal people do not appear to have greater life stress than others, they lack effective strategies to cope with stress. In addition, they are more likely than others to have had family loss and turmoil, such as the death of a family member, separation or divorce of their parents, or child abuse or neglect. The parents of those who attempt suicide have a greater frequency of mental illness and substance abuse than other parents. However, suicide occurs in all types of families, including those with little apparent turmoil.
Fluctuations in social and economic conditions frequently result in changes in the suicide rate. In the United States, for example, suicide rates declined during World War I (1914-1918) and World War II (1939-1945), when unemployment was low, but increased during the Great Depression of the 1930s, when unemployment was high. Occasionally, people commit suicide as a form of protest against the policies of a particular government. Mass suicides, in which large numbers of people kill themselves at the same time, are extremely rare. The most famous mass suicides occurred in AD 73 at Masada in what is now southern Israel, when 960 Jews killed themselves rather than face enslavement by Roman captors; and in 1978 in Jonestown, Guyana, when more than 900 cult members committed suicide on the orders of their leader, Jim Jones.
Because depression precedes most suicides, early recognition of depression and treatment through medication and psychotherapy are important ways of preventing suicide
(see Depression: Treatment). In general, suicide prevention efforts aim to identify people with the highest risk of suicide and to intervene before these individuals become suicidal.
(A) Risk Factors
Certain aspects of a person's life increase the likelihood that the person will attempt or complete suicide. Studies have shown that one of the best predictors of suicidal intent is hopelessness. People with a sense of hopelessness may come to perceive suicide as the only alternative to a pained existence. People with mental illnesses, substance-abuse disorders such as alcoholism or drug dependence, and behavioral disorders also have a higher risk of suicide. In fact, people suffering from diagnosable mental illnesses complete about 90 percent of all suicides. Physical illness also increases a person's risk of suicide, especially when the illness is accompanied by depression. About one-third of adult suicide victims suffered from a physical illness at the time of their death.
Other risk factors include previous suicide attempts, a history of suicide among family members, and social isolation. People who live alone or lack close friends may not receive emotional support that would otherwise protect them from despair and irrational thinking during difficult periods of life.
(B) Signs of Suicidal Intent
About 80 percent of people who complete suicide give warning signs, although the warnings may not be overt or obvious. These usually take the form of talking about suicide or a wish to die; statements about hopelessness, helplessness, or worthlessness; preoccupation with death; and references to suicide in drawings, school essays, poems, or notes. Other danger signs include sudden, dramatic, and unexplained changes in behavior and what are called "termination behaviors." These behaviors include an interest in putting personal affairs in order and giving away prized possessions, often accompanied by statements of sadness or despair.
A person who observes these signs should ask the person in question whether he or she is thinking of suicide. If so, the observer should refer the person to a trained mental health professional to reduce the immediate risk of suicide and to treat the problems that led the person to consider suicide. Most suicides can be prevented because the suicidal state of mind is usually temporary.
(C) Suicide Prevention Programs
In the United States, mental health professionals established the first major suicide-prevention telephone hotlines in the 1950s. Counselors or trained volunteers usually staff the hotlines around the clock. The staff members provide a listening ear to those in despair and tell callers where they can go to receive professional help. Although hotlines provide a valuable service to people in crisis, research has shown that hotlines help only those that call. Young women call more frequently than do men, who have a greater risk of suicide.
An increasing number of schools have suicide-prevention programs that train students, teachers, and school staff to recognize warning signs and tell them where to refer students at risk of suicide. These relatively new programs have not yet demonstrated their effectiveness at preventing youth suicide.
Another prevention method involves restricting access to means of killing oneself. Barriers that prevent people from jumping off bridges, for example, and restrictions on access to firearms have shown some effectiveness in reducing suicides. Such methods introduce a delay during which suicidal feelings and decisions may change or rescuers can physically intervene.
VI IMPACT ON OTHERS
Suicide has a devastating emotional impact on surviving family members and friends. The intentional, sudden, and violent nature of the person's death often makes others feel abandoned, helpless, and rejected. A family member or friend may have the added burden of discovering the body of the suicide victim. Parents often suffer exaggerated feelings of shame and guilt. Because of the social stigma, or shame, surrounding suicide, survivors may avoid talking to others about the person who died, and others may avoid the survivors. Despite these extra problems, research has shown that suicide survivors go through the same grieving process as other bereaved people and eventually recover from grief. Support groups may be particularly helpful for grieving suicide survivors.
Some evidence suggests that highly publicized suicides-those of celebrities, for example-may cause vulnerable individuals, especially teens, to kill themselves. However, these findings are controversial and other studies have found no such imitative effect.
VII ATTITUDES TOWARD SUICIDE
Many people feel uneasy talking about suicide, in part because of a social taboo on talking or learning about suicide. One popular myth is that suicide should not be mentioned around depressed people because it would plant the idea in their minds. But most mental health professionals agree that people who have suicidal wishes can benefit by talking about their feelings.
Attitudes toward suicide have varied widely throughout history. In ancient Egypt people considered suicide a humane way to escape intolerable conditions. For centuries in Japan people respected instances of hara-kiri (ritual suicide with a dagger) as a way for a shamed individual to make amends for failure or desertion of duty. During World War II Japanese kamikaze pilots considered it an honor to perform suicidal missions by crashing their airplanes into an enemy target. In India women were once expected to burn themselves on a funeral pyre after their husband died, a custom known as suttee.
In many other societies, however, suicide has been strongly condemned or made illegal. The Greek philosopher Plato strongly disapproved of suicide. In general, ancient Roman governments opposed suicide when the state stood to lose assets, such as soldiers and slaves. Suicide was clearly prohibited by Judaism unless one faced capture by an enemy, as in the mass suicides at Masada.
Christianity has generally condemned suicide as a failure to uphold the sanctity of human life. In the 4th century AD, Saint Augustine decreed suicide a sin. By the Middle Ages, the Roman Catholic Church forbade the burial of suicide victims in consecrated ground. English law considered suicide to be a crime punishable by the forfeiture of goods and property to the government unless the suicide was the result of madness or illness. This criminal view of suicide emigrated to colonial America and was adopted by individual states.
Today, with more modern views of mental illness and concern for the rights of survivors, most major religions offer compassion and traditional funeral rites in cases of suicide. No U.S. state now considers suicide a crime. Helping someone complete suicide, however, is criminally punishable in several states.
See also Euthanasia; Death and Dying; Thanatology.
Alan L. Bearman