“She was just there joking with all of us. She was getting ready for Valentine’s Day, explaining how much shopping she had to do, to have enough gifts for everyone. The last thing I thought about was that she would be ending her life.” Lola’s mother, Eileen, inconsolable, said these words to Claire, Lola’s clinician, after Lola was found in the park, hanging and then pronounced dead at the hospital. Claire could not hold back her tears, and being alone in her office, behind her phone, allowed her all the privacy she would need to tear up, with Lola’s mother on the other line.
For every hundred persons who die in the world, one will be due to suicide. Suicide is generally defined as intentionally causing one’s death. And a mental health condition is present 27% to 90% of the time. In fact, it has been shown that those with a history of psychiatric hospitalization have a lifetime risk of suicide, almost 10%, and about 40% of those who die by suicide had received mental health services within the year preceding their death.
While suicide happens every day, it is hard to “get used to it,” especially when its ramifications can be rather unpredictable. And given the strong link between suicide and health—mental health—there is a need for new strategies for suicide risk assessment. But before delving into these new strategies, let us consider an overview on suicide, looking at, (1) What the latest data can teach us and (2) The 11 risk factors for suicide.
What can the data teach us?
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The most commonly used method is based on availability of effective means.
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Some of the most common methods are firearms, hanging, and poisoning.
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Suicide is the 10th leading cause of death.
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Suicide has been increasing and not decreasing.
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Men are more likely than women to die by suicide (This difference is between 1.5 to 3.5 times more likely. However, suicide attempts are more common in women).
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Suicide is more common in those over 70 years old and those between 15 and 30 years old. Attempts, however, are overall more common in young people.
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Suicide notes are typically left in 15% to 40% of the cases.
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Major Depressive Disorder may have been present in 50% of those who died by suicide, while a personality disorder, especially Borderline Personality Disorder, may also have been present in that same number of cases. This data is related to psychological autopsy.
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The higher the rate of alcohol use in a specific country, the higher the rate of suicide.
Risk factors:
Who is more likely to die by suicide?
After looking at the nine (9) main data points, let us look at the eleven (11) main risk factors for suicide:
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Depression leads to a 20-fold increase risk for suicide
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Bipolar Disorder, like depression, increases the risk for suicide by 20-fold
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A diagnosis of Schizophrenia increases the risk for suicide by 14%. In this condition 5% of those affected will die by suicide
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Personality disorders lead to a 10% increase in risk
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Substance Use Disorder is considered the second most common risk factor, after a mood disorder. This risk is related to both the chronic nature of the substance use disorder and to acute intoxication. Further, alcohol and benzodiazepines have been shown to be the main two substances most commonly associated with suicide, with alcohol present in 15% to 61% of all cases. With ongoing issues regarding best practices around the use of benzodiazepines, it is worth emphasizing the role these medications play in increased rate of both suicide attempt and completion. This phenomenon is often related to side effects, including paradoxical effects, and other types of potential withdrawal symptoms that are not uncommon in those taking this group of medications, especially those with a severe trauma history, with severe personality disorder, or substance use disorder.
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Impulsive reaction in response to stressors or trauma and/or TBI
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Previous suicide attempts
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Access to lethal methods
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Subject to media reporting of suicide
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Cultural beliefs
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Genetic vulnerability carries an influential factor of 38% to 55%
“She was just there joking with all of us. She was getting ready for Valentine’s Day, explaining how much shopping she had to do, to have enough gifts for everyone. The last thing I thought about was that she would be ending her life.” Lola’s mother, Eileen, inconsolable, said these words to Claire, Lola’s clinician, after Lola was found in the park, hanging and then pronounced dead at the hospital. Claire could not hold back her tears, and being alone in her office, behind her phone, allowed her all the privacy she would need to tear up, with Lola’s mother on the other line.
In summary, suicide is real. Previously considered a crime in most countries, today, only some countries consider it criminal activity. We know that it is the 10th leading cause of death in both the United States and in the rest of the world. We have data telling us of its significance , and I have just outlined eleven (11) risk factors, over 90% of which are related to mental health. As mental health clinicians and related agency leaders, what should be our role in fostering new strategies for suicide risk assessment?
References:
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Preventing suicide: a global imperative. WHO. 2014. Pp. 7, 20, 40.
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GBD 2015 Mortality and Causes of Death, Collaborators. (8 October 2016). “Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015”. Lancet. 388 (10053): 1459–1544.
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Dodd’s TJ (2017). “Prescribed Benzodiazepines and Suicide Risk: A Review of the Literature”. Prim Care Companion CNS Disord. 19 (2).
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Yip, PS; Caine, E; Yousuf, S; Chang, SS; Wu, KC; Chen, YY (Jun 23, 2012). “Means restriction for suicide prevention”. Lancet. 379 (9834): 2393–9.
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Chang, B; Gitlin, D; Patel, R (September 2011). “The depressed patient and suicidal patient in the emergency department: evidence-based management and treatment strategies”. Emergency medicine practice. 13 (9): 1–23; quiz 23–4.
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Olson Robert (2011). Centre for Suicide Prevention. InfoExchange (3): 4
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Beck, A.T.; Resnik, H.L.P. & Lettieri, D.J, eds. (1974). “Development of suicidal intent scales”. The prediction of suicide. Bowie, MD: Charles Press. p. 41
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Simpson, G; Tate, R (December 2007). “Suicidality in people surviving a traumatic brain injury: prevalence, risk factors and implications for clinical management”. Brain injury: [BI]. 21 (13–14): 1335–51.
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Miller, M; Azrael, D; Barber, C (April 2012). “Suicide mortality in the United States: the importance of attending to method in understanding population-level disparities in the burden of suicide”. Annual Review of Public Health. 33: 393–408.
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Centers for Disease Control and Prevention, (CDC) (May 3, 2013). “Suicide among adults aged 35-64 years–United States, 1999-2010”. MMWR. Morbidity and Mortality Weekly Report. 62 (17): 321–5.