Suicidal behavior includes three types of self-destructive acts: completed suicide, attempted suicide, and nonsuicidal self-injury. 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-injury: An act of self-harm that is very unlikely to result in death. Such acts include inflicting superficial 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. Suicide is the 3rd leading cause of death among young people aged 10 to 24 and the 10th leading cause of death overall in the United States. When people are grouped by age, race, and sex , the suicide rate is highest in white males over age 85, but when people are grouped by age alone, the rate is highest in people aged 45 to 64.

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.

Suicide attempts are more common before middle age. Attempted suicide is particularly common among adolescent girls and single men in their 30s. 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. Suicidal behavior in children and adolescents is discussed in Chapter 287 (see Mental Health Disorders in Children: 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.

Risk Factors for Suicide
White Male Painful or disabling illness Living alone Debt or poverty Bereavement or loss Humiliation or disgrace Depression, especially when accompanied by psychosis or anxiety Persistent sadness even when other symptoms of depression are lessening A history of drug or alcohol abuse A history of prior suicide attempts A history of suicide in family members Traumatic childhood experiences, including physical or sexual abuse Preoccupation with and talk about suicide Well-defined plans for suicide

Causes

Suicidal behaviors usually result from the interaction of several factors. The most common is depression (see Mood Disorders: Depression). 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. About one in six people who kill themselves leaves a suicide note, which sometimes provides clues as to why.

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). The risk of suicide is higher if depression includes anxiety or features of psychosis, such as false beliefs (delusions), than if it does not.

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 (see Schizophrenia and Delusional Disorder: Schizophrenia) and other psychotic disorders may hear voices (auditory hallucinations) commanding them to kill themselves. People with borderline personality disorder (see Personality Disorders: Borderline personality disorder) or antisocial personality disorder (see Personality Disorders: 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—see Mood Disorders: Hypomania), 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 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.

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

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

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.

Suicide Intervention: National Suicide Prevention Lifeline
People threatening suicide are in crisis. The National Suicide Prevention Lifeline (1-800-273-TALK) provides crisis intervention for such people throughout the United States. Suicide prevention centers are staffed by specially trained volunteers. When potentially suicidal people call the hot line, a volunteer seeks to establish a relationship with them, reminding them of their identity (for example, by using their name repeatedly). The volunteer may offer constructive help for the problem that brought on the crisis and encourage them to take positive action to resolve it. The volunteer may remind them that they have family members and friends who care and want to help. Finally, the volunteer may try to facilitate emergency face-to-face professional help for them. Sometimes people call a hot line to say that they have already committed a suicidal act (for example, taken a drug overdose or turned on the gas) or are in the process of doing so. In such cases, the volunteer tries to obtain their address. If that is not possible, another volunteer contacts the police to trace the call and attempt a rescue. If possible, people are kept talking on the telephone until the police arrive.

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 (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, and Montana. In the rest of the United States, doctors can provide treatment intended to minimize physical and emotional suffering, but they cannot intentionally hasten death.

Last full review/revision April 2013 by Paula J. Clayton, MD