Risk Factors For Suicide

A statistical look at the social, biological, and psychiatric components associated with suicide: are there characteristics that suicidal people tend to share? One small study looked at a few such risk factors among New York teenagers:

In Table 7-1 below, column 2, the "odds ratio", shows the relative likelihood of someone with a particular risk factor killing themselves, compared to similar persons without that trait. In this study, the greatest risk factor was a prior attempt, 22.5 times the general population rate.

Table 7-1

Risk factors for male teenage suicide (New York City)

Risk Factor - prior attempt - odds ratio 22.5

Risk Factor - major depression - odds ratio 8.6

Risk Factor - substance abuse - odds ratio 7.1

Risk Factor - antisocial behavior - odds ratio 4.4

Risk Factor - family history of suicide - odds ratio 3

The fact that the U.S. suicide rate has been fairly stable over several decades suggests that our ability to identify and treat the suicide-prone has not improved much, though it's certainly possible that the rate would be higher without such improvements as have occurred.

In other words, our ability to anticipate, using any or all sociological, psychological, or biological measurements now available, if a particular individual will or will not commit suicide, remains negligible. In the words of psychiatrist Alex Pokorny.

"Although we may reconstruct causal chains and motives after the fact, we do not possess the tools to predict particular suicides before the fact.

The conclusion is inescapable that we do not possess any item of information or any combination of items that permit us to identify to a useful degree the particular persons who will commit suicide.

Even for someone in a high-risk category the chances of suicide within a year are much less than the chance that he will not have committed suicide within that time. In twenty-five years I can remember perhaps three cases where I felt the chance of a certain person committing suicide within the next year was more than 10 percent."

Pokorny makes a distinction between long-term prediction, about which he is pessimistic, and short-term crises (minutes, hours, or days) which, he argues, requires identifying a crisis that is already here, and which, he feels, psychiatrists do reasonably well.

However, clinical judgement seems unreliable for predicting suicide attempts: as noted earlier, a computer program was superior to experienced clinicians in identifying patients who would attempt suicide.

The current situation still seems to be, no one knows why people kill themselves. Trying to find the answer is like trying to pinpoint what causes us to fall in love or what causes war.

There is no single answer. Suicide is not a disease like cancer or polio. It is a symptom. "The problem of suicide cuts across all diagnoses," says John Mack, a psychiatrist and coauthor of Vivienne, the story of a fourteen-year-old girl who hanged herself. "

Some are mentally ill, most are not. Some are psychotic, most are not. Some are impulsive, most are not." Says psychologist Pamela Cantor, "People commit suicide for many reasons. Some people who are depressed will commit suicide, and some people who are schizophrenic will commit suicide, and some people who are fine but impulsive will commit suicide.

We can't lump them all together." And just as there is no one explanation for the five thousand adolescent suicides each year, there is no one explanation for any one suicide."

Does bringing up the subject of suicide with a depressed person put the idea into her head?

No; you can be sure that the idea was already there. However, "If they are feeling suicidal, it can come as a great relief to see that someone else has some insight into how they feel."

What do suicide-attempt survivors think of suicide?

"Many people have speculated that if you could talk to someone who was in midair after jumping from a tall tower, you might find out that he no longer was so sure he wanted to die. Over the past thirty years I have seen four people who survived six-story suicide jumps.

"Two wished to survive as soon as they jumped, two said they did not, but one of the latter two who professed to be furious at having survived made no subsequent suicide attempt."

Similarly, of 515 people who had been prevented from jumping off the Golden Gate bridge, only 25 (5%) went on to kill themselves later. Of eight known survivors in 1975, one subsequently killed himself.

According to another source, only 2% of survivors of suicide attempts objected to having been saved, while 70% said their suicide was "stupid".

The same author, Jaques Choron, cites Japanese data that claim 90% of survivors studied were happy to be saved. Similar studies from Norway found that 57-75 percent of suicide survivors said they were glad that their attempt had failed.

It seems also to be the case that surviving a serious suicide attempt sometimes ends depressions, even if there is permanent injury. Hendin suggests that sometimes a self-inflicted permanent injury is "therapeutic" in the sense that it satisfies a need for self-punishment.

On the other hand, our inability to interview dead people, generally the most serious and thorough of attempters, limits our knowledge of their interest in being saved.

Warning Signs

How would I know if someone close to me was considering suicide?

There are two general strategies, that overlap to some degree: awareness of (1) sociological or biological risk factors and (2) individual signals.

The generally more familiar method consists of sensitivity to various verbal and behavioral signs; but the fact is, while many people consider, mention, or threaten suicide, far fewer make a suicide attempt. Probably the closest we can get to knowing is to ask, usually not a comfortable question to think about, let alone ask.

The most important suicide warning signs are:

(1) A previous suicide attempt. Between 20-80 percent of suicides (studies vary wildly) have made one or more prior attempts. Whatever the actual number, this is the single most significant flag.

(2) A major change in behavior or personality. A normally cheerful person may become quiet and withdrawn, and stop formerly-pleasurable activities. Insomnia, or more often an excess of sleep, may be seen. Giving away prized possessions is sometimes a sign that a decision for suicide has been made. However, in all of these and other changes, alternative reasons for the behavior are entirely possible.

(3) Reckless behavior. "I don't care" or "leave it to chance" actions are close to out-and-out suicidal behavior. An example of this is "Russian roulette".

(4) Severe depression. Some of the components of depression are hopelessness, inability to concentrate, sleep disturbances, feelings of worthlessness, loneliness, and sadness. Such a person might say things like, "You would be better off without me," or "Everything I touch turns into ashes." However, some people are so depressed that they don't have the energy to kill themselves. These folks are actually at higher risk when they're just starting to feel a little better.

As one suicidal woman noted, "it takes a tremendous amount of energy to figure out how you're going to kill yourself, I wanted something that was final and wasn't going to be messy. I didn't want to jump off the roof; I might end up only half dead, and I wouldn't like that. I didn't want to blow my head off, I didn't happen to feel that physical disembodiment would be a particularly pleasant thing for everybody. I kept thinking about what would be easiest for everyone else. Of course the easiest thing would have been if I'd lived."

Since thought disturbances and hopelessness are generally associated with depression, severely depressed people may not recognize the serious nature of their problem, or, if they do, lack the will to try to get help.

"Their thought processes often seem tailored to narrow possibilities, for their rigidity often makes them unable to see alternative solutions, while depression alters their judgement about possibilities for the future."

"When I was nineteen, I had my first deep depression. I was terrified. Everything, the way I walked, the way I talked, slowed to a crawl. I felt empty, like everything inside me had been cut up and pulled out. It was as if something had died inside me and was disintegrating. I couldn't concentrate. Reading a book, I'd find myself skimming the same passage over and over until I'd realize I had read the same paragraph sixteen times.

After eight months I began to wonder whether my depression would ever lift. I envisioned spending my whole life like that. The feeling that it was never going to end is what made me think of suicide.", Anne-Grace Scheinin.

She made six suicide attempts in the two years before being diagnosed as manic-depressive and being treated with lithium. There were no suicide attempts in the following 10 years.

(5) Talking, or dropping clues, about committing suicide. This is usually an indirect, but unmistakable, plea for help, and shouldn't be ignored. Adolescents, in particular, generally place high value on independence, privacy, and self-reliance. If they're asking for help, they're probably in serious pain.

The idea that people who talk about suicide won't carry it out is dead wrong. Erwin Stengel estimates that three fourths of the people who either commit suicide or make an attempt give clear warning of their intent; perhaps some act because they were not taken seriously.

On the other hand, depression is often hidden ("The mass of men lead lives of quiet desperation." --Thoreau) or unnoticed. Thus, as discussed later, physicians often don't recognize depression in their patients.

Is suicide appropriate? Is intervention appropriate? Who decides? When is Suicide Justified?

People have been arguing this question for millennia. There are about one thousand books in print on suicide in the United States. Sherwin Nuland, physician and author of How We Die, puts it well when he says, "...the importance of airing different viewpoints rests not in the probability that a stable consensus will ever be reached but in the recognition that it will not. It is by studying the shades of opinion expressed in such discussions that we become aware of considerations in decision-making that may never have weighed in our soul-searching."

Some people think suicide is never justified. A minority argue the merits of suicide: it allows one to choose (as much as one can choose these things) the time, place, manner, cause, purpose, and painfulness of death, and maintain that it is a decision each individual must make.

Most of us would understand why someone might prefer suicide if she were in uncontrollable pain. Many would, I think, agree with Nuland when he says, "Taking one's own life is almost always the wrong thing to do. There are two circumstances, however, in which that may not be so. Those two are the unendurable infirmities of a crippling old age and the final devastations of a terminal disease."

As philosopher Richard W. Momeyer puts it more formally, "suicide is an act that does not occur in a vacuum, and it is ordinarily not without very serious and often devastating consequences for others. Even if it can be claimed as a right, it is not inappropriate that one be very careful to assure that exercising that right is the right thing to do.

Having a right to do something provides us some entitlement to do it; it does not assure that doing it is right. It is appropriate to set very high standards of justification for exercising a right to suicide, given how often it is undertaken in an ill-considered manner, how frequently suiciders suffer diminished competence from mental illness, and how widespread and serious are the consequences for others..."

Intervention In Suicide

There seem to be two central questions about intervention to stop suicide: (1) under what (if any) circumstances and (2) by what means, is it appropriate?

Most people would argue that suicide intervention is justified in the absence of terminal illness. This is especially true if the potential suicide is young; her thinking is impaired by depression, alcohol, or other drugs; she is ambivalent; or there's likelihood of "improvement", i.e., a change of mind or condition. On the other hand, about two thirds of Americans feel that suicide or euthanasia is sometimes proper for people who are dying.

However, the issue becomes less clear when one asks, "For how long, and by what methods, may the exercise of the right to suicide be limited?" For example, should someone be locked up or drugged solely because she may commit suicide? If so, for how long? In the U.S., "...suicidal persons are the only people who may be held against their will for weeks, months, or even years on the sole basis of what they `might' do in the future rather than what they have done in the past, and not to others but to themselves.

One Arizona woman spent fifty-eight years without comprehensive review in a state mental hospital after a suicide attempt. "If a sociologist predicted that a person was 80 percent likely to commit a felonious act, no law would permit his confinement," comment the authors of an article on "Civil Commitment of the Mentally Ill: Theories and Procedures" in the Harvard Law Review.

"On the other hand if a psychiatrist testified that a person was mentally ill and 80 percent likely to commit a dangerous act, the patient would be committed."

The Supreme Court, in its wisdom (joke), has seen fit to provide weaker safeguards of due process and standards of proof in civil commitment cases than in criminal cases. In criminal cases the standard of proof for guilt is "beyond a reasonable doubt" and accepts that it's better for a guilty person to go free than for an innocent one to be unjustly imprisoned.

In spite of this principle, the Court does not "...appear to believe, as it does in criminal cases, that it is better for a mentally ill person to go free than for a normal individual to be committed."

Whether someone is involuntarily hospitalized depends, to a substantial extent, on social factors: age, sex, status, older, female, and lower socio-economic-class people are more likely to be involuntarily committed, and whether the patient has a lawyer at the commitment proceedings.

In addition, psychiatrists consistently overestimate the danger to and by the patient in commitment hearings. This is not surprising, since (1) psychiatrists' ability to accurately predict who will commit suicide is small; and (2) the consequences to the psychiatrist, and (perhaps) to the patient, are much more severe if a released patient commits suicide than if the psychiatrist mistakenly hospitalizes someone.

And, if the patient kills himself while hospitalized, this can be cited as evidence of the need for the hospitalization, however regrettable the outcome.

Is ambivalence about suicide, for example, seeking help, calling a hotline, or standing on a ledge, sufficient grounds for intervention? Ambivalence means wanting, or being undecided between, two mutually exclusive things, in this case, "life" and "death".

The problem with suicide is that we can go from life to death but not from death to life; a hundred decisions for life are overcome by a single one for death. One can argue that what suicides want is not death but the end to their pain, however it be achieved, and that life = pain and death = end of pain. The results, however, are the same.

Ambivalence toward suicide is indicated by the fact that three fourths of all suicides communicate their intentions, often with the hope that something will be done to make their suicide unnecessary. In a high proportion of cases, such communications are varied, repeated, and expressed to more than one individual. Studies of those who have survived serious suicide attempt have revealed that a fantasy of being rescued is frequently present.

But even if you and I can agree that intervention is sometimes appropriate, what are we to do with the suicidal people who do not agree? May we force them to take mind-altering drugs? For how long? Electroshock? How many times? Lock them up? For how many days, months, years? By what right may we continue to intervene in the face of someone's persistent demand to make the decision as to the time and manner of his death? Ultimately the question cannot be evaded: "Whose life is it?"

How do clinicians treat suicidal people?

"The immediate goal of a therapist, counselor, or anyone else dealing with highly suicidal people should be to reduce the pain in every way possible....Help them by intervening with whoever or whatever is causing their distress, lovers, parents, college deans, employers, or social service agencies. I have found that if you reduce these pressures and lower the level of suffering, even just a little, suicidal people will choose to live., Edwin Shneidman"

This is not always as gratifying as it sounds: some suicidal people are "...extremely difficult: provocative, ambivalent, openly hostile, or passive-aggressive and vengeful." Thus, the clinician's first job is to manage his or her own feelings generated by the crisis situation and not be driven by discomfort.

The clinician can act out in a variety of ways, from failing to inquire about suicidality with an obviously upset or depressed person ("It sounds bad, but surely you're not suicidal."); by fleeing from the subject when the patient brings it up ("Uh-huh. And how's your appetite?"); by actively colluding with the patient's wish to commit suicide ("Sounds like there isn't any reason for you to live."); or by openly or covertly directing the patient to die ("Why don't you do it right the next time!")

Can treatment prevent suicide attempts?

Though often useful, professional help is no guarantee against suicide. Two thirds of the suicides in one study had consulted their family doctor within a week of their death. In another study, over 90 percent of suicides had been seen by a psychiatrist or a family doctor within a year of death; 48 percent within a week. However 48 percent of physicians were "very surprised" by the suicide of their patient.

In fairness to GPs, most of these people came in with somatic complaints: headache, insomnia, tiredness, backache, and so forth. In addition patients are often on their best behavior at the doctor's and tend to minimize their own psychiatric problems.

It's also the case that a substantial number of these suicides saw the physician specifically to get enough drugs to kill themselves. In one study, this motivation was found in 43 percent of drug-overdose deaths immediately (within 24 hours) following physician visits.

All of this does not imply that therapy is useless or counterproductive any more than the fact that many people who see heart specialists end up dying from heart disease; only that it is far from universally effective.

On the other hand, current anti-depressant drugs are fairly good at making people feel better, about 75 percent of users seem to be helped, and should certainly be tried by just about anyone considering suicide. However, they don't work instantly and might take as long as six weeks to show an effect, and the dose may need be adjusted for an optimal response.

Drug treatment should be generally continued for several months; less than 4.5 months of anti-depressant use is associated with an increased rate of treatment failure. In addition, most of these drugs work for some people but not for others, possibly requiring trials with more than one anti-depressant.

In a study of people in New York City who killed themselves between 1990-92, 16.4 percent (268/1635) had been taking anti-depressants. This is similar to data from Sweden where 15.9 percent (542/3400) of suicides had been using anti-depressants.

It is not clear if this is good news (a lot of suicides might not have killed themselves had they been using medication) or bad news (a lot of people taking anti-depressants kill themselves anyway).

In fact, while most anti-depressants are reasonably good at making people feel better, they are less effective in decreasing suicidal thoughts and behavior.

This is particularly true of the older tricyclics (TCAs) such as amitriptyline (e.g., Elavil) and imipramine (e.g., Tofranil). In fact one, maprotiline (Ludiomil), significantly increased suicidal behavior, 14 suicide attempts among 777 patients compared to 1 attempt among the 374 patients taking no medication.

Particularly interesting is that a low dose was just as suicide-provoking as a higher dose, while less effective in decreasing depression. The implication is that lower doses of such drugs, sometimes chosen for "safety", may be equally dangerous and less therapeutic than higher doses.

Curiously, none of the 5 completed suicides was by maprotiline overdose, even though it is a fairly toxic drug.

More recent anti-depressants of a type called "serotonin-specific reuptake inhibitors" (SSRIs), like Prozac (fluoxetine), Welbutrin (bupropion) and Effexor (venlafaxine), seem to be safer, somewhat more effective, and faster acting than either TCAs or MAOIs, especially in severe depression or where there is a large anxiety component of the depression.

However, there is some evidence suggesting that fluoxetine itself can cause suicidal thoughts and/or behavior.

But, even effective anti-depressants can be a two-edged sword: sometimes they make people feel just enough better to have the energy to kill themselves, as well as providing them the means to do so.

Especially in adolescents and in people experiencing severe depression for the first time, it's important to remember the probability that, as Leigh Orf says, "...in six short months someone who was threatening suicide daily will change their tune to `Gee, am I glad I didn't off myself' because of some rather insignificant event, in the Grand Scheme of Things, like finding a new friend, significant other, or hobby."

Does Hospitalization Help?

In the heat of this argument, an important question is often overlooked: Does hospitalization help? The answer is far from clear. Suicide rates in psychiatric hospitals are roughly five times higher than on the outside. and there have been suicide epidemics inside such institutions.

Some of the anti-suicide regimens, such as 24-hour-a-day watch, or isolation may be terrifying or enraging to the patient/prisoner, and may be imposed because of the staff's fear of being accused of not having done everything possible to prevent a potential suicide.

Some evidence that has been uncritically used to support hospitalization is subject to other interpretations. For example, one study found that a significant number of hospitalized mental patients killed themselves while temporarily at home on leave.

This was taken to mean that it was the return to the scene and situation at home that triggered the suicide. The notion that an unwillingness to go back to the hospital might have been the catalyst was never examined.

Similarly, the fact that seven percent of a group of recently released psychiatric patients killed themselves was used to make a case for hospitalization. But, as psychiatrist Herbert Hendin notes, "There is as much justification for concluding that...the experience of hospitalization contributed to the suicide as there is for maintaining that hospitalization would have prevented it....For some acutely suicidal patients it may be life saving....Other suicidal patients are made more upset by their confinement.

The decision for hospitalization is too often made, not on the basis of a realistic evaluation of whether it will help a particular patient, but because therapists want to shift the responsibility for a possible suicide onto an institution."

We're all going to die eventually; the only uncertainties are "when" and "how". Why, then, does suicide bother us in a way and to a degree that numerically greater, and easier to prevent, causes of death, like automobile wrecks (40,000-50,000/year) or cigarette smoking (400,000/year) don't?

Writer Jaques Choron speculates, "it has been suggested that suicide "troubles and appalls us because it so intransigently rejects our deeply held conviction that life must be worth living."

"While there is undoubtedly some truth in this, in more cases than one would like to admit the reason for the shock may not be the challenges to the belief that life is good, but the fact that one is not really quite sure that it is. As...[Spanish philosopher] Jose Ortega y Gasset noted, for most people at all times "life" meant limitation, obligation, dependence, and oppression.

They go on living simply because they happen to have been born, sustained by the force of habit, sometimes out of curiosity or vague hopes for a better future, and because they are afraid of the alternative--death. But the suicide seems to have conquered this fear. Thus he confirms not only the suspicion that life may not be the highest good but the one that death may not be the greatest evil."

Choron goes on to ask, "Should not the multitudes who die painfully and miserably each year be allowed to decide for themselves what is best for them? Moreover, it would be interesting to ascertain how many among physicians, whose suicide rate is many times that of the average population, are actually euthanatic suicides, due to the discovery of their own terminal illness, their knowledge of how prolonged and painful dying can be, and the easy accessibility of quick-acting lethal drugs."

Good question. There are high suicide rates among physicians: about 3% of male and 6.5% of female U.S. physicians' deaths in 1986 were suicides, 35% of premature deaths among physicians were due to suicide, suicide is the leading cause of death for physicians under 40 years old, and the suicide rate for psychiatrists is almost twice that for other doctors.

Data from Australia also show moderately elevated suicide rates for male physicians, and substantially higher rates for female doctors. And in Switzerland, the problem is so severe that the life expectancy of female physicians is ten years less than that of the general female population.

from suicide and attempted suicide by geo stone.